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DocuSign Envelope ID: B92DA393-A597-41 FA-A852-9AB8C7D2575B
<br /> ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br /> 04/07/2017
<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 have ADDITIONAL INSURED provisions or be endorsed.
<br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br /> PRODUCER ACT Amy H. Paschal
<br /> Ken B. Lawson,Jr. (A/C,NNo,Ext): 919-846-2090 ext 105 FAX,No): 919-846-2438
<br /> Ken Lawson,Jr.Agency E-MAIL E paschaa@nationwide.com
<br /> y ADDRSS: p h nationwide.com @
<br /> 6512-101 Six Forks Road INSURER(S)AFFORDING COVERAGE NAIC#
<br /> Raleigh, NC 27615 INSURERA: Nationwide Mutual Insurance Company 23787
<br /> INSURED INSURER B: NorGUARD Insurance Company 25844
<br /> ProNet Systems, Inc. INSURER C:
<br /> 3200 Glen Royal Road INSURER D:
<br /> Suite 107 INSURER E:
<br /> Raleigh, NC 27617 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 R TYPE OF INSURANCE I S POLICY EFF POLICY EXP
<br /> NSD VD POLICY NUMBER
<br /> T W LIMITS
<br /> (MM/DD/YYYY) (MM/DD/YYYY)
<br /> A X COMMERCIAL GENERAL LIABILITY y ACP GLO 2292994383 02/22/2017 02/22/2018 EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE X OCCUR PRSRENTED
<br /> PREMISES(( 100 Ea occurrence) $ ,000
<br /> X Contractual Liability MED EXP(Any one person) $ 5,000
<br /> X Contractor's Enhancement PERSONAL&ADV INJURY $ 1,000,000
<br /> GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
<br /> POLICY Xi 'Ea LOC PRODUCTS-COMP/OP AGG $ 2,000,000
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
<br /> (Ea accident)
<br /> ANY AUTO BODILY INJURY(Per person) $
<br /> OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS ONLY AUTOS
<br /> HIRED NON-OWNED PROPERTY DAMAGE
<br /> AUTOS ONLY AUTOS ONLY (Per accident)
<br /> A X UMBRELLA LIAB X OCCUR y ACP CAF 229994383 02/22/2017 02/22/2018 EACH OCCURRENCE $ 4,000,000
<br /> X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000
<br /> DED X RETENTION$ none $
<br /> B WORKERS COMPENSATION PRWC836165 04/03/201704/03/2018 X PER OTH-
<br /> AND EMPLOYERS'LIABILITY STATUTE ER
<br /> Y/N
<br /> ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
<br /> OFFICER/MEMBEREXCLUDED? y 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 /> Tools and Equipment Installation Floater $75,000. Limit
<br /> A Commercial Inland Marine ACP CIM 2292994383 02/22/2017 02/22/2018 Contractors Equip $22,250. Limit
<br /> All Job Sites of the Insured $500./141000. Ded Respectively
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Orange County is included as additional insured and Waiver of Subrogation applies per Blanket Contractors Enhancement
<br /> Endorsement CG 72 88 under the general liability policy(please refer to attachments). The Umbrella/Excess Liability policy is"follow
<br /> form". Blanket Waiver of Subrogation also applies to the workers compensation policy(please refer to attachments).
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Orange County
<br /> P. O. Box 8181 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> Hillsborough, NC 27278 ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> E-Mail: tcomar @orangecountync.gov AUTHOR)ZEDREPR ENTATVE
<br /> E-Mail: anitaj @pronetsystemsnc.com /
<br /> E-Mail: patf @pronetsystemsnc.com 4 :4,« a + t,,":.� w. ..•
<br /> ("/ ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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