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DocuSign Envelope ID:69F93BE5-OFF1-412C-9392-F34F64FCO20C <br /> AC° DATE(MM/DD/YYYY)® CERTIFICATE OF LIABILITY INSURANCE 11/4/2016 <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 CONTA y e�CT Beverly Pik AAI <br /> NAME: <br /> Jake A Parrott Insurance Agency Inc (A/CNNo,Ext): (252)523-1041 /C No): (252)523-0195 <br /> 2508 N HERRITAGE STREET E-MAIL p <br /> b p ike@ arrottins.com <br /> ADDRESS: <br /> PO BOX 3547 INSURER(S)AFFORDING COVERAGE NAIC# <br /> KINSTON NC 28502 INSURERA:EMPLOYERS MUTUAL CASUALTY CO 21415 <br /> INSURED INSURER B:EMCASCO INSURANCE COMPANY 21407 <br /> TILE RESTORATION INC INSURER C: <br /> PO BOX 160 INSURER D: <br /> INSURER E: <br /> HOOKERTON NC 28538-0160 INSURERF: <br /> COVERAGES CERTIFICATE NUMBER:16-17 MASTER 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 ADDL SUER POLICY EFF POLICY EXP LIMITS <br /> LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> DAMAGE TO RENTED 500,000 <br /> A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ <br /> 5D20546 11/7/2016 11/7/2017 MEDEXP(Anyoneperson) $ 10,000 <br /> PERSONAL&ADV INJURY $ 1,000,000 <br /> GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 <br /> X POLICY PRO- <br /> JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> 1,000,000 <br /> (Ea accident) <br /> X ANY AUTO BODILY INJURY(Per person) $ <br /> A ALL OWNED SCHEDULED <br /> AUTOS AUTOS 5E20546 11/7/2016 11/7/2017 BODILYINJURY(Peraccident) $ <br /> NON-OWNED PROPERTY DAMAGE <br /> HIRED AUTOS AUTOS (Per accident) <br /> Medical payments $ 5,000 <br /> X UMBRELLALIAB OCCUR EACH OCCURRENCE $ 2,000,000 <br /> EX <br /> A MESS LIAR CLAIMS-MADE AGGREGATE $ 2,000,000 <br /> DED RETENTION$ 5J20546 11/7/2016 11/7/2017 $ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 <br /> OFFICER/MEMBER EXCLUDED? N/A <br /> B <br /> (Mandatory in NH) 5H2O546 11/7/2016 11/7/2017 E.L.DISEASE-EA EMPLOYEE$ 1,000,000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> CERTIFICATE HOLDER IS LISTED AS AN ADDITIONAL INSURED AS PERTAINS TO GENERAL LIABILITY, ON A PRIMARY <br /> BASIS INCLUDING PRODUCTS & COMPLETED OPERATIONS, VIA A WRITTEN CONTRACT IN PLACE WITH THIS REQUIREMENT <br /> INCLUDED. CERTIFICATE HOLDER IS LISTED AS AN ADDITIONAL INSURED AS PERTAINS TO AUTO LIABILITY, VIA A <br /> WRITTEN CONTRACT IN PLACE WITH THIS REQUIREMENT INCLUDED. WAIVER OF SUBROGATION IN FAVOR OF ADDITIONAL <br /> INSURED APPLIES TO GENERAL AND AUTO LIABILITY AND WORKER'S COMPENSATION, VIA A WRITTEN CONTRACT IN PLACE <br /> WITH THIS REQUIREMENT INCLUDED. <br /> EXCLUDED OFFICERS IN WORKER'S COMPENSATION COVERAGE: DAVID ALBRITTON & CHARLES ALBRITTON III. <br /> CERTIFICATE HOLDER CANCELLATION <br /> tcomar @orangecountync.gov <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> ORANGE COUNTY 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 /> H Reynolds/HEATHE EL —P-N <br /> ©1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <br /> INS025 r7mdm i <br />