2017-024-E AMS - ASD-Asphalt Services On Demand - CO to 2016-576-E for repaving parking lot at Skills Developmen

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DocuSign Envelope ID: F4E9815A-D9D2-4217-83BE-B882B3C57138 ---- -� ASPHA-1 OP ID: DO '4"4C ---- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/4....---- 10/12/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS 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). CONT PRODUCER NAMEACT Danielle Ohlendorf Pittman Insurance Group, LLC PHONE FAX 5838 Faringdon Place (NC,No,Ext):919-878-8028 (NC,No): 919-876-4567 Raleigh,NC 27609 ADDRESS: danielle@pittmaninsurancegroupllc.com Hasten McDermott INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:NW Mutual Fire Insurance Co. 23779 INSURED Asphalt Services on Demand INSURER B:Accident Fund Insurance Co of 10166 959 Short Journey Road Smithfield,NC 27577-8266 INSURER C Selective Insurance Co.of Ame 12572 INSURER D:Mt. Hawley 37974 INSURER E:NW Mutual Insurance Company 23787 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY ACP3017155310 06/21/2016 06/21/2017 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ � CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY X MT LOC $ JEC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 000 000 (Ea accident) $ , , C X ANY AUTO S2218622 04/13/2016 04/13/2017 BODILY INJURY(Per person) $ X ALL NED X SCHEDULED BODILY INJURY(Per accident) $ AUTOOS W AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS JPER ACCIDENT) $ X UMBRELLA LIAB )( OCCUR EACH OCCURRENCE $ 4,000,000 D EXCESS LIAB CLAIMS-MADE EMX0321560 04/14/2016 04/14/2017 AGGREGATE $ 4,000,000 DED RETENTION$ $ WORKERS COMPENSATION X WC STATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE WCV 611323100 06/21/2016 06/21/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? y N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Inland Marine ACP3017155310 06/21/2016 06/21/2017 Limit 970,522 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD