2016-287-E Planning - Pilot Environmental, Inc. for Phase 1 Site Assessment

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DocuSign Envelope ID: DE50C3DC-2C59-4045-8605-848OD42217C5 75/9/2016 TE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 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 Jeff Edmonds NAME: Chappell Insurance Agency, Inc. HONE Ext: (336)356-8087 A/C No: (336)356-9153 209 S Main Street ADDRESS:Jeff @chappellinsuranceagency.com PO BOX 829 INSURER(S)AFFORDING COVERAGE NAIC# Dobson NC 27017 INSURERA:Everest Indemnity Insurance Company 10851 INSURED INSURER B:Hartford Underwriters Insuranc Pilot Environmental, Inc. INSURER C: PO BOX 128 INSURER D: INSURER E: Kernersville NC 27285 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1641902141 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 SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE A CLAIMS-MADE � OCCUR PREM SESOEa occurrence)l $ 50,000 X EF4ML05624-161 4/17/2016 4/17/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ECT 1:1 LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Employee Benefits $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED AUTOS AUTOS EF4ML05624-161 4/17/2016 4/17/2017 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident X UMBRELLA LAB OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB X CLAIMS-MADE AGGREGATE $ 2,000,000 DED X RETENTION$ 10,000 EF4CU00861-161 5/20/2016 5/20/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? � N/A B (Mandatory in NH) 6S60UB2E15595916 4/17/2016 4/17/2017 E.L.DISEASE-EA EMPLOYE $ 1 000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Professional Liability EF4ML05624-161 4/17/2016 4/17/2017 EACH OCCURENCE 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION hfleming @orangecountync.go SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Planning Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 131 W Margaret Lane ACCORDANCE WITH THE POLICY PROVISIONS. Suite 201 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Jeff Edmonds/JE1 ' ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r9mnm t