2016-654-E AMS - Tibbens Construction to install access hatch

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DocuSign Envelope ID:8AD3FDAA-DCB9-475F-880E-66361 E37859C MARKT-1 OP,JD;.EC CERTIFICATE LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/21/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO JIGHTS 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 CONTACT All United Insurance Agency Co All United Insurance Agency 9716-B Rea Road,#123 (A/C, Ext):866-484-8656 FAX No): 866-362-9807 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:United Specialty Insurance Co. Mark Tibbens Construction 849 Moose Tracks Trail INSURER C:North Carolina Rating Bureau 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 300,000 B X COMMERCIAL GENERAL LIABILITY X CL1729215 11/18/2015 11/18/2016 DAMAGE TO RENTED PREMISES(Ea occurrence) $ 500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY _ $ 300,000 GENERAL AGGREGATE _ $ 600,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG_ $ 600,000 X POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000 000 (Ea accident) _ $ e B X ANY AUTO BIO9698J 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 __(PER ACCIDENT) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 41B44722 09/06/2016 09/06/2017 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 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 more space is required) Orange County is listed as additional Insured with respect to the General Liability Policy as required by written contract. CERTIFICATE HOLDER CANCELLATION ORANGE1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE All United Insurance Agency Co ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD •