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DocuSign Envelope ID:28DA00F8-4193-4A09-B5AF-6D4761 A9B655 <br /> A01213 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> 9/15/2016 <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 NAMEACT Leah Spence <br /> Cothran Insurance PHONE 434-239-2886 FAX 434-237-0085 <br /> 423 Laxton Road (A/C,No,Ext): (NC,No): <br /> Lynchburg VA 24502 ADDRESS:cois @cothraninsurance.com <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A:Nationwide Mutual Insurance Co 23787 <br /> INSURED FOURS-1 INSURER B:Nationwide Mutual Fire Ins Co 23779 <br /> FOUR STAR PETROLEUM INSURER c:Accident Fund <br /> SERVICES INC <br /> 622 HUNTINGTON BLVD NE INSURER D:Homeland Ins Co of NY <br /> ROANOKE VA 24012-3547 INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 79800192 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 DOCUMENT 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 /> INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W /Y LIMITS <br /> LTR INSD VD POLICY NUMBER (MM/DD YYY) (MM/DD/YYYY) <br /> A x COMMERCIAL GENERAL LIABILITY ACPGL02436156994 5/15/2016 5/15/2017 EACH OCCURRENCE $1,000,000 <br /> CLAIMS-MADE X OCCUR <br /> DAMAGE TO RENTED <br /> PREMISES( <br /> SES(Ea occurrence) $100,000 <br /> MED EXP(Any one person) $5,000 <br /> PERSONAL&ADV INJURY $1,000,000 <br /> GE 'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $2,000,000 <br /> POLICY PRO- <br /> JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 <br /> OTHER: $ <br /> A AUTOMOBILE LIABILITY ACPBA2436156994 5/15/2016 5/15/2017 COMBINED SINGLE LIMIT $ <br /> (Ea accident) 1,000,000 <br /> X ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS AUTOS <br /> NON-OWNED PROPERTY DAMAGE <br /> HIRED AUTOS AUTOS (Per accident) <br /> B X UMBRELLA LIAB X OCCUR ACPCAF2426156994 5/15/2016 5/15/2017 EACH OCCURRENCE $2,000,000 <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> C WORKERS COMPENSATION WCV6100948 4/1/2016 4/1/2017 PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 <br /> OFFICER/MEMBER EXCLUDED? N/A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 <br /> D Contractors Pollution 793-00-46-59-0000 5/15/2016 5/15/2017 Occurrence 1,000,000 <br /> Aggregate 1,000,000 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> The certificate holder is an additional insured and/or waiver of subrogation applies in favor of holder <br /> if required by written contract prior to loss via endorsement CG7331. <br /> Orange County, its officers, official agents and employees are additional insureds with respect to GL as <br /> required by written contract via endorsement CG7331. We will endeavor to provide 30 days advance notice <br /> for cancellation or material change in coverage. <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Orange County Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 200 South Cameron St <br /> Hillsborough NC 27278 <br /> AUTHORIZED REPRESEN ATIVE <br /> ©1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <br />