2016-456-E DEAPR - Summit Design and Engineering Services for construction materials testing

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DocuSign Envelope ID:4236F103-A289-4D68-B8B0-1 B6COD115E45 DocuSign Envelope ID:7DEFBC40-ACE8-418F-A707-78004D4F60A4 A °® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 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 PHONE (919)968-4611,E �: (919)968-4611 FAX Nol:(919)968-8991 800 Eastowne Drive, Suite 208 E-MAIL ADDRESS:ewalker®business-insurers.com PO Box 2536 INSURER(S)AFFORDING COVERAGE NAICB- Chapel Hill NC 27515-2536 INSURER A:OhiO Security 24082 24082 INSURED INSURERB:PeerlesS Indemnity Ins Co 18333 Summit Design And Engineering Services Pile INSURERC:Ohio Casualty Insurance Co 24074 24074 504 Meadowlands Dr INSURER D: INSURER E: Hillsborough NC 27278 INSURER F: COVERAGES CERTIFICATE NUMIE'.ER: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 UMITS LTR INSD WVD POLICY NUMBER (MMIDD!YYYY).IMMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000 AMAGE A CLAIMS-MADE X OCCUR PREMSESIOEnoccurrence) $ 300,000 X Y 05555764212 1/1/2016 1/1/2017 MED EXP(Any one person) $ 15,000 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO POLICY X JECT LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: Experience Mod Factor 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea aodden0 B X ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED x y 5A8907931 4/2/2016 4/2/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS N-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) $ Experience Mad Factor 2 $ X UMBRELLA LIAR OCCUR EACH OCCURRENCE _5 6,000,000 C EXCESS LIAR CLAIMS-MADE AGGREGATE $ 6,000,000 DED X RETENTIONS 10,000 US055764212 1/1/2016 1/1/2017 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN r X I STATUTE PRH ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER N!A A (Mandato(Mandatory ry in NH)EXCLUDED? N Y XW555764212 1/1/2016 1/1/2017 EL.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS 1 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 ��G��. Y/�- ei-Z.-ems ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 omann