2016-560-E DEAPR - Clark Poe Construction, Inc. to move historic Hollow Rock Store

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DocuSign Envelope ID:453C1A54-9B45-4FE0-9E13-2B8723D592A7 POECL-1 OP ID: DS ACOR° CERTIFICATE OF LIABILITY INSURANCE DATE 08/26/2016Y) 08/26/2016 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 Christopher Ives Rubish High&Rubish Insurance Agency PHONE 919-913-1144 FAX 919-913-1155 P.O.Box 3040 (A/C,No,Ext): (A/C,No): 6015 Farrington Rd.Ste 101 E-MAIL chrisr hi handrubish.com Chapel Hill,NC 27517 ADDRESS: 9 Jeffrey A.Rubish INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Owners Insurance Company 32700 INSURED Clark Poe Construction Inc INSURER B Builders Mutual Insurance Co 134 Granger Rd Chapel Hill,NC 27516-4503 INSURER C: 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. I POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER W LIMITS (MM/DD/YYYY) (MMlDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 35228565 02/18/2016 02/18/2017 DAMAGE TO RENTED 300,000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 POLICY PRO- JECT $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 500,000 (Ea accident) $ A X ANY AUTO 5063197100 02/18/2016 02/18/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS JPER ACCIDENT) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X WC STATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE WCP104101001 08/06/2016 08/06/2017 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if mom space is required) CERTIFICATE HOLDER CANCELLATION ORANG-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ORANGE COUNTY ENVIRONMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AGRICULTURE, PARKS AND RECREATION PO Box 881 AUTHORIZED REPRESENTATIVE HILLSBOROUGH,NC 27278 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD