2016-145-E DEAPR - Summit Design and Engineering Services, PLLC for soil borings

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DocuSign Envelope ID: D10D47AF-6B34-46E7-8866-5A58AA29E9A8 kw� CERTIFICATE OF LIABILITY INSURANCE® =TIE /DD/YYYY)/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ellen Walker NAME: Business Insurers of Carolinas PHONE Ext: (919)968°4611 A/C No:(919)968-8991 800 Eastowne Drive, Suite 208 E-MAIL ADDRESS:ewalker @business-insurers.com PO Box 2536 INSURERS AFFORDING COVERAGE NAIC# Chapel Hill NC 27515-2536 INSURERA:Ohio Security 24082 24082 INSURED INSURERB:Peerless Indemnity Ins Co 18333 Summit Design and Engineering Services PLLC INSURERC:Ohio Casualty Insurance Co 24074 24074 504 Meadowland Drive INSURER D: INSURER E: Hillsborough NC 2727$ 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL15121414193 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDDY/YYYY POLICY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE � OCCUR PREMISES Ea occurrence $ 300,000 BKS55764212 1/1/2016 1/1/2017 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Experience Mod Factor 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS AUTOS BA8907831 4/2/2015 4/2/2016 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ Ex erience Mod Factor 2 $ X UMBRELLA LIAB OCCUR Umb excess over GL,Auto & EACH OCCURRENCE $ 6,000,000 C EXCESS LIAB CLAIMS-MADE WC AGGREGATE $ 6,000 000 DED I X RETENTION$ 10,000 USO55764212 1/1/2016 1/1/2017 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER . ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000 A (Mandatory in H)EXCLUDED? XWS55764212 1/1/2016 1/1/2017 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Dept of Environment, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Agriculture, Parks and Recreation ACCORDANCE WITH THE POLICY PROVISIONS. Marabeth Carr 306 A Revere Road AUTHORIZED REPRESENTATIVE PO Box 8181 Hillsborough, NC 27278 Ellen Walker/ELLEN <�� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(701401)