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DocuSign Envelope ID:595F86A3-E7A8-4291-9C8B-CD13A314E128 AMERIN1 OP ID: C4
<br /> ACC:WC,' DATE(MMIDDr(WY)
<br /> �,,,,,, CERTIFICATE OF LIABILITY INSURANCE 03/24/2016
<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 1NSURER(S), AUTHORIZED
<br /> PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> ?ORTANT: 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
<br /> Scott Ins(Greensboro) NAME: Carolee Templeton Fax -4
<br /> 628 Green Valley Road Ste.306 (Arc,No,Ext)336-510 0090 No)
<br /> (NC, _434 55-8832
<br /> Greensboro,NC 27408 EMAIL •
<br /> Steve Heston-Greensboro ADDRESS:cfiempleton@scottins.com
<br /> INSURER S AFFORDING COVERAGE NAIC e
<br /> •
<br /> INSURER A:Pe nn National SecuritylnsCoA- 32441
<br /> INSURED American Industrial INSURERS:PennNationalMutualCas Ins CoA- 14990
<br /> Contractors,Inc.
<br /> PO Box 16224 INSURER C:
<br /> Greensboro, NC 27416 INSURER 0:
<br /> INSURER E:
<br /> ■
<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 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 /> lLT- -- — -- ADDL SUBRt POLICY EFF ' POLICY EXP ------
<br /> R, TYPE OF INSURANCE LIMITS
<br /> LTR IINSD IAMB( POLICY NUMBER (MMIDDIYYYYI ''IMM/DMIW1f)
<br /> A I X I COMMERCIAL GENERAL LIABIUTY ( I i EACH OCCURRENCE 1 $ 1,000,000
<br /> ! `— `D-l+Tu AGETOITE
<br /> —
<br /> CLAIMS-MADE X- OCCUR 1 X 1 1CX9 0681271 04/01/2016 04/01/2017:PREMISES(Ea occurrence) ' $ _ 100,000
<br /> —--- MED EXP(Any one person) j$ 5,000
<br /> � � � PERSONALBADV INJURY I$ _ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
<br /> 1 POLICY X II JECT LOC j PRODUCTS-COMP/OP AGO $ 2,000,000
<br /> OTHER: (Emp Ben. s 1,000,000
<br /> UTOMOB I.E LIABILITY 1 I COMBINED SINGLE LIMIT g 1,000,000
<br /> l (Ea accldentl _ _.... _-_
<br /> X ANY AUTO !Axe 0681271
<br /> 04/01/2016 04/01/2017 1 BODILY INJURY(Per person) $
<br /> -* ALL OWNED SCHEDULED i 1-
<br /> AUTOS _ AUTOS
<br /> BODILY INJURY(Per accident) $
<br /> y i NON-OWNED PROPERTY DAMAGE $
<br /> HIRED AUTOS X )AUTOS
<br /> 1 (Per accident)
<br /> $
<br /> _ 1 i
<br /> X UMBRELLA LIAB X OCCUR EACH OCCURRENCE I $ 3,000,000
<br /> B EXC X RETENTION$ CLAIMS-MADE 100001 1 04/01/2017'AGGREGATE I $ 3,000,000
<br /> EXCESS uAB lUL9 0681271 04/01/2016
<br /> 'WORKERS COMPENSATION X STATUTE I ER—1..
<br /> (Mandatory in NH) Y/N N/A 04/01/2016 j 04/01/2017 E.L.EACH ACCIDENT 1$ 500,000
<br /> A ANY PROPRIETOR/PARTNER/EXECUTIVE _ -
<br /> OFFICER/MEMBER EXCLUDED') I ``�
<br /> AND EMPLOYERS'LIABILITY
<br /> WP9 0681271 I E.L.DISEASE-EA EMPLOYEE!$ _ 500,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below . ; , I E.L.DISEASE-POLICY LIMIT I $ 500,000
<br /> A 1Leased/Rent Equip 1CX9 0681271 ; 04/01/20161 04/01/2017 /$250 Ded 125,000
<br /> A (Install Floater CX9 0681271 04/01/20161 04/01/2017($2500 Ded 1,000,000
<br /> i 1 i
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,mw be attached if more space is required)
<br /> Orange County Solid Waste is listed as and additional insured with regards
<br /> to general liability where required by written contract
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> ORANG-1
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> Orange County Solid Waste THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> g tY o aste ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> P.O.Box 17177
<br /> Chapel Hill, NC 27516 AUTHORIZED REPRESENTATIVE
<br /> ( --44---
<br /> -
<br /> O 1988-2014 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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