2016-422-E AMS - Tibbens Construction - SHSC interview rm. #5 renovation

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DocuSign Envelope ID:9F65F1 B2-3BE4-4133-A023-C80F60F07140 MARKT-1 OP ID: LM CERTIFICATE LIABILITY I DATE(MM/DD/YYYY) 04/20/2016 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 All United Insurance Agency Co All United Insurance Agency PHONE FAX 9716-B Rea Road,#123 (A/c,No,Exu:866-484-8656 (A/c,No): 866-362-9807 ,Charlotte,NC 28277 E-MAIL All United Insurance Agency Co ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Insurance 11066 INSURED Mark Tibbens DBA INSURER B Mark Tibbens Construction 849 Moose Tracks Trail INSURER C: Cedar Grove, NC 27231 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 SWVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS - (MMIDD/YYYY) (MMIDDIYYYY) GENERAL LIABILITY EACH OCCURRENCE $ 300,000 A X COMMERCIAL GENERAL LIABILITY X MPG1466K 02/28/2016 02/28/2017 DAMAGE T O PREMISES(Ea RENTED 500,000 $ ,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) _ $ 10,000 PERSONAL&ADVINJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 600,000 X POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000 000 (Ea accident) B X ANY AUTO BI09698J 11/18/2015 11/18/2016 BODILY INJURY(Per person) $ ALL OVVNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS _PER ACCIDENT) $ UMBRELLA LIAB OCCUR • EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Job Location: Whitted Building 308 Tryon Street Hillsborough NC 27278 -- Orange County is listed as additional Insured with respect to the General Liability Policy as required by written contract. CERTIFICATE HOLDER CANCELLATION ORANGEI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g y ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough, NC 27278 -° AUTHORIZED REPRESENTATIVE CD /V, /� I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD