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DocuSign Envelope ID:C9D9221A-83A4-4F8F-AD2E-2AE626464D77
<br /> °""e� ALPHA-8 OP ID: LO
<br /> „.r CERTIFICATE OF LIABILITY INSU NCE DATE(MMIDDAI/YYY)
<br /> `� 11115!2016
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOR''I`ATION 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 NAME:ACT Lori Hamlet
<br /> TriSure Corporation-KS PHONE 2473 469- FAX
<br /> 4325 Lake Boone Trail INC.No,Ext):919-469-2473 _ djAIC,No): 919-467-4987 _
<br /> Suite 200 n DRESS:(hamlet @trisure.com
<br /> Raleigh,NC 27607 —
<br /> SokOfowski&Assoc.,LLC INSURER(S)AFFORDING COVERAGE NAIC If _
<br /> INSURER A:Travelers Indemnity Co. 25658
<br /> INSURED Alpha and Omega Group PC INSURER B:Catlin Specialty Insurance Co.
<br /> Ted Bartelt
<br /> INSURER C:Selective Insurance Co. 12572
<br /> 4601 Lake Boone Trail Ste 3C
<br /> Raleigh, NC 27607 INSURER D_
<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 /> INSR TYPE OF INSURANCE A++L.t-* POLICY EFF POLICY EXP
<br /> INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) LIMITS
<br /> A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,001
<br /> 1 CLAIMS-MADE OCCUR 6804F999705 05/19/2016 05/19/2017 DAMAGE TO RENTED 30O+001)
<br /> PREMISES(Ea occurrence)-__.-$
<br /> X Business Owners
<br /> MED EXP(Any one person) $ 5,001
<br /> PERSONAL S ADV INJURY $ 1,000,001
<br /> GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,001
<br /> POLICY n PRO
<br /> JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000
<br /> OTHER:
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
<br /> (Ea accident) +
<br /> A X ANY AUTO BA4F999766 06/19/2016 06/19/2017 BODILY INJURY(Per person) $
<br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) S
<br /> AUTOS AUTOS
<br /> HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
<br /> AUTOS (Per accIdent)
<br /> X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000
<br /> A EXCESS LIAR H CLAIMS-MADE CUP4F999809 06/19/2016 05/19/2017 AGGREGATE $ 5,000,000
<br /> DED X RETENTION$ 10,000 $
<br /> WORKERS COMPENSATION X STATUTE 1 ER
<br /> Y!N
<br /> A ANY PROPRIETOR/PARTNER/EXECUTIVE UB4387T266 05/19/2016 06/19/2017 E.L.EACH ACCIDENT $ 1,000,000
<br /> OFFICER/MEMBER EXCLUDED? N/A
<br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,001
<br /> B Professional Liab AED-9000421-0616 05/19/2016 05/19/2017 Claim/Agg $1M/$2M
<br /> C Rent/Leased Equip 52236365 09/09/2016 05/19/2017 Limit 100,001
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
<br /> Operations of the Named Insured covered by the above referenced policies.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> ORA8181
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> g y ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Department of Environment,
<br /> Agriculture,Parks&Rec. AUTHORIZED REPRESENTATIVE
<br /> P 0 Box 8181
<br /> Hillsborough, NC 27278 4. , If ,
<br /> 1
<br /> ©1988-2014 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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