2017-136-E AMS - Tibbens Construction to install door between new single occupancy restroom and locker room

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DocuSign Envelope ID:6CBDC816-7157-47E6-991 B-C295A7AB3612 MARKT-1 OP ID: EC cORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `••-- 01/12/2017 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 All United Insurance Agency Co All United Insurance Agency PHONE FAX 9716-B Rea Road,#123 (A/C,No,Ext):866 484-8656 (A/C,No): 866-362-9807 Charlotte,NC 28277 E-MAIL All United Insurance Agency Co ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Main Street America Insurance 11066 INSURED Mark Tibbens DBA INSURER B:United Specialty Insurance Co. 12537 Mark Tibbens Construction 849 Moose Tracks Trail INSURER C:North Carolina Rating Bureau Cedar Grove, NC 27231 INSURER D: INSURER E: 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. IN SR TYPE OF INSURANCE I POLICY EFF POLICY EXP INSR WVD POLICY NUMBER /Y LIMITS (MM/DD YYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 300,000 B X COMMERCIAL GENERAL LIABILITY X CL1729215 11/18/2016 11/18/2017 DAMAGE TO RENTED PREMISES(Ea occurrence) $ 500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 600,000 X POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 000 000 (Ea accident) $ , , B X ANY AUTO X B109698J 11/18/2016 11/18/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS APER ACCIDENT) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 41B44722 09/06/2016 09/06/2017 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate Holder is listed as Additional Insured as required by written contract with respect to the General Liability policy. CERTIFICATE HOLDER CANCELLATION ORANGEI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE a County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Oran g ty ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE !1"!e .44e7) ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD