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DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 20BOYSGIR2
<br /> ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)11/03/2016
<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 CONTACT Terrie G. Roberts
<br /> NAME:
<br /> BB&T Insurance Services, Inc. PHONE 919 281-4500 FAX ): 8887468761
<br /> (A/C,No,Ext): (A/C,No
<br /> Post Office Box 13941 E-MAIL 1.:.
<br /> ro
<br /> t g berts^bbandt.com
<br /> ADDRESS:
<br /> Durham, NC 27709 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> 919 281-4500 INSURER A:Riverport Insurance Company 36684
<br /> INSURED INSURER B:FirstComp Insurance Company 27626
<br /> Boys &Girls Club of Greater Durham INSURER C:Travelers Indemnity Company 25658
<br /> PO Box 446
<br /> INSURER D:
<br /> Durham, NC 27702-0446
<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 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 /> LTR L POLICY EFF POLICY EXP
<br /> TYPE OF INSURANCE SR WVD POLICY NUMBER
<br /> N LIMITS
<br /> (MM/DDIYYYY) (MM/DDIYYYY)
<br /> A X COMMERCIAL GENERAL LIABILITY 13242855 09/09/2016 09/09/2017 EACH OCCURRENCE $1,000,000
<br /> CLAIMS-MADE X OCCUR
<br /> DAMAGE TO RENTED $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 $3,000,000
<br /> PRO-
<br /> POLICY JECT LOC PRODUCTS-COMP/OP AGG $3,000,000
<br /> OTHER: $
<br /> A AUTOMOBILE LIABILITY 13242855 09/09/2016 09/09/2017 (Eo acccdentSINGLE LIMIT $1,000,000
<br /> X ANY AUTO BODILY INJURY(Per person) $
<br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS AUTOS
<br /> X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE
<br /> AUTOS (Per accident)
<br /> A x UMBRELLA LIAB OCCUR BINDER13242856 09/09/2016 09/09/2017 EACH OCCURRENCE $1,000,000
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000
<br /> DED RETENTION$ $
<br /> B WORKERS COMPENSATION MWC005544003 09/09/2016 09/09/2017 STATUTE EORH
<br /> AND EMPLOYERS'LIABILITY
<br /> Y/N
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000
<br /> OFFICER/MEMBER EXCLUDED? y 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 /> C D&O/Empl Prac 105991654 09/09/2014 09/09/2017 1,000,000
<br /> A Professional Liab 13242855 09/09/2016 09/09/2017 1,000,000/3,000,000
<br /> A Sexual Abuse 13242855 09/09/2016 09/09/2017 1,000,000/3,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> **Workers Comp Information**
<br /> Other States Coverage
<br /> Proprietors/Partners/Executive Officers/Members Excluded:
<br /> Jerome Levisy, CEO
<br /> (See Attached Descriptions)
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Orange County Risk Manager SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> g y g er THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Hillsborough, NC 27278
<br /> AUTHORIZED REPRESENTATIVE
<br /> ©1988-2014 ACORD CORPORATION.All rights reserved.
<br /> ACORD 25(2014/01) 1 of 2 The ACORD name and logo are registered marks of ACORD
<br /> #817079500/M 16784881 TGR
<br />
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