Orange County NC Website
Browse       Search
DocuSign Envelope ID: C057BFCE-FE50-48B8-990C-1588389F9587 <br /> MARKT-1 OP ID:JE <br /> CERTIFICATE OF LIABILITY DATE(MM/DD/YYYY) <br /> 04/14/2016 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> All United Insurance Agency All United Insurance Agency Co <br /> PHONE FAX <br /> 9716-B Rea Road,#123 A/c No Ext;866-484-8656 A/c No): 866 362-9807 <br /> Charlotte,NC 28277 E-MAIL <br /> All United Insurance Agency Co ADDRESS: <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A:Main Street America Insurance 11066 <br /> INSURED Mark Tibbens DBA INSURER B: <br /> Mark Tibbens Construction <br /> 849 Moose Tracks Trail INSURER C: <br /> Cedar Grove, NC 27231 INSURER D: <br /> INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> ILTR TYPE OF INSURANCE DDL UBR POLICY NUMBER MM/DD/YYYY MM/DD�YY LIMITS <br /> GENERAL LIABILITY EACH OCCURRENCE $ 300,000 <br /> A X COMMERCIAL GENERAL LIABILITY X MPG1466K 02/28/2016 02/28/2017 PREMISES Ea occurrence $ 500,000 <br /> CLAIMS-MADE FxI OCCUR MED EXP(Any one person) $ 103000 <br /> PERSONAL&ADV INJURY $ 300,000 <br /> GENERAL AGGREGATE $ 600,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 600,000 <br /> X POLICY PRO LOC $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 <br /> Ea accident <br /> B X ANY AUTO B109698J 11/18/2015 11/18/2016 BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED <br /> AUTOS AUTOS BODILY INJURY(Per accident) $ <br /> HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ <br /> L 1 $ <br /> AUTOS PER ACCIDENT <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAR CLAIMS-MADE AGGREGATE $ <br /> DED I I RETENTION$ $ <br /> WORKERS COMPENSATION WC STATU- OTH- <br /> AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) <br /> Job Location: Whitted Building 308 Tryon Street Hillsborough NC 27278 <br /> I <br /> CERTIFICATE HOLDER CANCELLATION <br /> i <br /> ORNGCOU <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Orange Count THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> g y ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 131 West Margaret Lane <br /> Hillsborough, NC 27278 <br /> AUTHORIZED REPRESENTATIVE <br /> All United Insurance Agency Co <br /> ©1988-2010 ACORD CORPORATION: All rights reserved. <br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD <br /> I <br />