Orange County NC Website
DocuSign Envelope ID: 34D18779-D403-42E9-B265-960F4F5ED000 <br /> GILFSTI OP ID: C1 <br /> A,C . CERTIFICATE OF LIABILITY INSURANCE DATE(MM�DDIYYYY) <br /> 08/12/2015 <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 •i ' <br /> NAME: Philip S.Wolf <br /> The Insurance Center of Durham PHONE FAx <br /> 1920 Front St.,Suite 710 ac,_No,Exl)919-471-2541 j(A/c,NoJ;919-471-2132 <br /> P.O.Box 15369 EMAIL <br /> Durham, NC 27704- ADDRESS:Phil @insurancecenterofdurham.cotn <br /> Philip S.Wolf 1NSURER(S)AFFORDING COVERAGE NAIL f1__ <br /> INSURERA:AUto-OWnerS Insurance Co. 18988 <br /> INSURED Statler W.Gilfilien& INSURERS: _ <br /> Valerija Gilfillen - <br /> 3302 Saint Marys Rd. INSURER c; <br /> Hillsborough, NC 27278-9726 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 DOCUTAE T 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 /> INSitl _ ...... .- -ADDL SUBR - .... POLICY EFF POLICY EXP _. _ .. <br /> LTR i TYPE OF INSURANCE INS!) WVD POLICY NUMBER (MM/DD(YYYY) (MM/DD/YYYYJ LIMITS <br /> A X 1 COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000 <br /> OR NT�A <br /> CLAIMS-MADE rX OCCUR X 35447799 08/11/2015 08/11/2016 DAMAGETPREMISES_(Eaoccurrence)--$__- 60,000 <br /> I MED EXP(My one parson) $ 5,000 <br /> - <br /> I PERSONAL&ADV INJURY $ Excluded <br /> Ir , <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 <br /> I PRO- f ... <br /> POLICY; X 1 JECT L 1 LOC PRODUCTS-COMPIOP AGG [__$ 2,000,000 <br /> •OTHER: � --...._.._._._ ..-------- $ <br /> AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ <br /> ANY AUTO <br /> BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED • <br /> 1. AUTOS _ AUTOS BODILY INJURY(Per accident) $ <br /> • <br /> • NON-OWNED PROPERTY DAMAGE $ <br /> HIRED AUTErS __ AUTOS (Per accident) <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> I ; EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> RETENTION$ <br /> DED $ <br /> WORKERS COMPENSATION ; PER ; 1OTH- <br /> !AND EMPLOYERS'LIABILITY YIN I,STATUTE.1f_ER ,_-____._............._._...._-_. <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE 1 N!A E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory In NH) E.L,DISEASE-EA EMPLOYEE $ <br /> Ilfyes,descibeundar .........._....._.._..__...._.. __-...____.-_..__...--.__._..._I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> I <br /> i <br /> • <br /> DESCRIPTION OF OPERATIONS I LOCATIONS(VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) <br /> Management Consultant,Architect <br /> CERTIFICATE HOLDER CANCELLATION <br /> ORAN016 <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Orange County ACCORDANCE WITH THE POLICY PROVISIONS, <br /> PO Box 8181 <br /> • <br /> Hillsborough,NC 27278 AUTHORIZED REPRESENTA ! <br /> Philip S.Wolf L 8/ <br /> ©1988-2014 ACORD COR RATION. All rights reserved. <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <br /> i <br />