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DocuSign Envelope ID:80160778-AE5F-4DC7-AAC5-2C5C76CD400D
<br /> Client#:25609 PENTENGI
<br /> DATE(MM/DD/YYYY)
<br /> O TM CERTIFICATE F LIABILITY INSURANCE 10/06/2016
<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 CONTACT Carly Underwood
<br /> Greyling Ins. Brokerage/EPIC PHONE 770.552.4225 FAx o) 866.550.4082
<br /> (AIC,No,Ext): (A/C,N :
<br /> 3780 Mansell Road,Suite 370 E-MAIL rt un caerwoo re n
<br /> ADDRESS: y d d @g Il
<br /> y g•com
<br /> Alpharetta,GA 30022 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURER A:Nautilus Insurance Company 17370
<br /> INSURED INSURER B:Great Divide Insurance Company 25224
<br /> PENTA Engineering Group,Inc. Ohio Security Insurance Company 24082
<br /> INSURER C: Y P Y
<br /> 4000 Miller Court West
<br /> INSURER D:
<br /> Norcross,GA 30071
<br /> INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 16-17 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 /> LTR TYPE OF INSURANCE INSR POLICY EFF POLICY EXP
<br /> WVD POLICY NUMBER
<br /> N LIMITS
<br /> (MM/DDIYYYY) {MM/DD/YYYY)
<br /> A COMMERCIAL GENERAL LIABILITY ECP201603711 10/08/2016 10/08/2017 EACH OCCURRENCE _$1,000,000
<br /> CLAIMS-MADE X OCCUR PREMISES(UEa oocurrrence) $100,000
<br /> MED EXP(Any one person) $5,000
<br /> PERSONAL&ADV INJURY $1,000,000
<br /> GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
<br /> PRO-
<br /> POLICY JECT LOC
<br /> PRODUCTS-COMP/OPAGG $2,000,000
<br /> X
<br /> OTHER: $
<br /> C AUTOMOBILE LIABILITY BAS56938550 10/08/2016 10/08/2017 pa aBci ED)INGLE LIMIT _$1,000,000
<br /> ANY AUTO BODILY INJURY(Per person) $
<br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS AUTOS
<br /> NON-OWNED PROPERTY DAMAGE
<br /> X HIRED AUTOS AUTOS (Per accident)
<br /> A UMBRELLA LIAB X OCCUR FFX201603811 10/08/2016 10/08/2017 EACH OCCURRENCE $4,000,000
<br /> )( EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000
<br /> DED X RETENTION$0 $
<br /> B WORKERS COMPENSATION WCA201603611 10/08/2016 10/08/2017 X ;MUTE EMPLOYERS'LIABILITY STATUTE ER
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000
<br /> OFFICER/MEMBER EXCLUDED? N 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 $1,000,000
<br /> A Professional Liab ECP201603711 10/08/2016 10/08/2017 Per Claim/Agg$1M/$2M
<br /> Contractors Poll. ECP201603711 10/08/2016 10/08/2017 PerCondition$1,000,000
<br /> Liability Aggregate$2,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Excess Liability includes Professional Liability,Contractors Pollution Liability,and CGL.Professional
<br /> Liability in primary and Excess policies is claims-made.Aggregate Limits of$2,000,000 in primary CGL,PL
<br /> and CPL applies to all three coverage parts.Aggregate limit of$4,000,000 in Excess Liability applies to
<br /> CGL,PL and CPL.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Orange County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> g y 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 /> ©1988-2014 ACORD CORPORATION.All rights reserved.
<br /> ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD
<br /> #S564970/M564650 CUND1
<br />
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