2016-504-E AMS - Tibbens Construction for CGCC upgrade window

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DocuSign Envelope ID: E8CB95E7-533C-49AF-92F5-8C9FC602256D MARKT-1 OP ID:LM W R CERTIFICATE F 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 NAMEACT All United Insurance Agency Co All United Insurance Agency PHONE 866-484-8656 FAX 866-362-9807 9716-B Rea Road,#123 (A/C,No,EXt): (A/C,No): 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 SUBR POLICY EFF POLICY EXP LTR 1h1SR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 300,000 A X COMMERCIAL GENERAL LIABILITY X MPG1466K 02/28/2016 02/28/2017 DAMAGE TO RENTED 500 000 PREMISES(Ea occurrence) $ , CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 600,000 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 OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS JPER 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 Or Or Box C1 u1 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE 41, "//44,--) I _ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD