2016-258-E DEAPR - Summit Design and Engineering Services for geotechnical services

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DocuSign Envelope ID:7DEFBC40-ACE8-418F-A707-78004D4F6OA4 ACOORL> CERTIFICATE OF® DATE(MM/DD/YYYY) LIABILITY INSURANCE 5/11/2016 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 PHON o ,,, (919)968-4611 FAX No:(919)968-8991 800 Eastowne Drive, Suite 208 E-MAIL ewalker@business-insurers.com ADDRESS: 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 Casualt Insurance Co 24074 24074 504 Meadowlands Dr INSURER D: INSURER E: Hillsborough NC 27278 INSURER F: COVERAGES CERTIFICATE NUMBER:CL164114973 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 EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYY MM/DDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑OCCUR DAMAGE TO RENTED 300,000 PREMISES Ea occurrence $ X Y 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 X JECT POLICY PRO—[::] LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Experience Mod Factor 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident B X ANY AUTO BODILY INJURY(Per person) $ A O SCHEDULED AUU TOS S AUTOS X BA8907831 4/2/2016 4/2/2017 BODILY INJURY(Per accident) $ y NON-OWNED PROPERTY DAMAGE X HIRED AUTOS Ix AUTOS Per accident $ Experience Mod Factor $ X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 61000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 6,000,000 X $DED RETENTION WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE I ER ANY PROPRIETOR/PARTNER/EX ECUTIVE NIA E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? A (Mandatory in NH) y xWS55764212 1/1/2016 1/1/2017 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Phase I ESA - Efland Hrs Soccer Property Orange County 2015-2016 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 S Cameron Street ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough, NC: 27278 AUTHORIZED REPRESENTATIVE Ellen Walker/ELLEN � � ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(?()14(111