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DocuSign Envelope ID: C0D2E252-5690-4859-8AEA-DAE216A7A561
<br /> LAWRE-1 OP ID: MG
<br /> Aoc- R CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)
<br /> 12/20/2016
<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 NAMEACT PhillipAllen
<br /> Thompson-Allen,Inc. PHONE FAQ
<br /> P.O.Box 100 _laic,No,Ext):336-599-2_176 _(/c Nat: 336-599-6932
<br /> Roxboro, NC 27573 ADDRESS:
<br /> Marcia D.Green
<br /> INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURER A:Cincinnati Insurance Company i` 10677
<br /> INSURED Tommy Lawrence Electrical INSURER a:Cincinnati Casualty Company 28665
<br /> P.O.Box 641
<br /> Roxboro,NC 27573 INSURERC: ,
<br /> INSURER D_
<br /> j
<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 - AODLISUB --- --- "-! POLICY EFF ; POLICY EXP i_ ----- _�
<br /> LTR TYPE OF INSURANCE INSDLWVD} POLICY NUMBER (MMIOD/YYYY)'(MMIDDIYYYY){ LIMITS
<br /> A X 1 COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE 5 500,000
<br /> I- "" r ' I DAMAGE TO RENTED-----^------
<br /> 1 I CLAIMS-MADE I XWI OCCUR j �EPP 0096783 1 08/16/2016:08/16/2017 PREMISES(Ea occurrence) 5 100,000
<br /> -,
<br /> MED EXP(Any one person) S 5,000
<br /> PERSONAL&ADV INJURY .s 500,000
<br /> GENT.AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 1,000,000
<br /> —I ,. .. PRO-
<br /> POLICY I ]JECT ; ] LOC PRODUCTS-COMP/OPAGG .$ 1,000,000
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 15 1,000,000,000,000
<br /> {Ea accident).___ —
<br /> A X f ANY AUTO _ EBA 0096783 08/16/2016 j 08/16/2017 BODILY INJURY(Per person) 15
<br /> ALL OWNED -'SCHEDULED BODILY INJURY(Per accident) $
<br /> I AUTOS AUTOS
<br /> NON-OWNED PROPERTY DAMAGE ,5 --
<br /> HIRED AUTOS AUTOS I ..(Per accident)
<br /> $
<br /> 1 I UMBRELLA LIAB, X OCCUR I I , O_.—...__
<br /> X � ! ' EACH OCCURRENCE 5 5,000,000
<br /> A EXCESS LIAB I 1 CLAIMS-MADE IEPP 0096783 08/16/2016 08/16/2017 j AGGREGATE_ S 5,000,000
<br /> 4
<br /> DED I I RETENTION$ 1 i �
<br /> F — J— 5
<br /> WORKERS COMPENSATION j I I,PER 1 0TH-
<br /> !AND EMPLOYERS'LIABILITY Y/N I t„_ STATUTE�_—LER
<br /> B ANY PROPRIETOR/PARTNER/EXECUTIVE IEWC 0368238-01 01/01/2016 01/01/2018 LE.L.EACH ACCIDENT 5 100,000
<br /> ;OFFICER/MEMBER EXCLUDED? N/A
<br /> (Mandatory In NH) I E.L.DISEASE-EA EMPLOYEE S _, _100,000 If,DESs,RIPTIONunder I E.L.DISEASE-POLICY LIMIT $ 500,000
<br /> 1DESCRIPTIONOFOPERATIONSbelow f
<br /> j
<br /> 1
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more spaoo is required)
<br /> EMAIL: Itaft©orangecountync.gov
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> ORANGCG
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> Orange County Government ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Parks and Recreation
<br /> Lori Taft AUTHORIZED REPRESENTATIVE
<br /> 200 South Cameron Street M D. r en`
<br /> Hillsborough, NC 27278 mW�' W �S!(��
<br /> I
<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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