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DocuSign Envelope ID: E271A49A-1BD2-4431-90DF-FC9C4F52CE69
<br /> ACC)R/
<br /> CERTIFICATE OF IAh DATE(MMIDDIYYYY)
<br /> 'ILITY INSURANCE _ DATE
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br /> CE""?TIFICAT'E DOES NOT AFFI'"'MATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED Y 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 OS WAIVED,subject to the
<br /> 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 ... .. _..... .. ..- .. ...
<br /> Greg Lopeman, CPCU NAME: Greg Lopeman„ ".
<br /> PHONE FAX
<br /> State Farm Insurance fAIP Na Ext) 919-933-7770 Arc,Noy 919-933-7713
<br /> E-MAIL
<br /> 104-8 NC Hwy 54 W ADDRESS:Greg Lopeman,NYSL©Statefarm.com
<br /> Carrboro, NC 27510 INSURER(S)AFFORDING COVERAGE NAIL#
<br /> INSURED INSURER A State Farm Fire and Casualty Company 4 25143
<br /> RILEY SURVEYING PA INSURER B:State Farm Mutual Automobile Insurance Company - 25178
<br /> STE 100B INSURER C
<br /> 3326 DURHAM CHAPEL HILL BLVD INSURER 0
<br /> INSURER E
<br /> DURHAM NC 27707-2695
<br /> .. __. _._ ........ ......_. _- .1,-INSURER F t . ._.. ...._ _...... ....
<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 ..___...... .-------. . .,,,... ....._.-_._--- >AODLLSUBR.... -..._.._.____....------- -------
<br /> "P©LICYEFF POLICY EXP
<br /> TYPE OF INSURANCE I ........_....LTR ,INSR WYD POLICY NUMBER (MMlDD1YYYY) (MMIDD/YYYYI LIMITS
<br /> GENERAL LIABILITY w..-
<br /> A Y 93-B5-K546-3 02/2012016 02120/2017 EACH OCCURRENCE S 1,000,000
<br /> X COMMERCIAL GENERAI.LIABILITY DAMAGE TO RENTE))
<br /> ---- { 93-CG-2005-8 02120120/7 02/20/2018 PREMISES(Ea Oraurence) $ 300,000
<br /> '.� CLAIMS-MADE X] OCCUR MED EXP(Any one person) $ 5,000
<br /> PERSONAL&ADV INJURY 1,000,000
<br /> " GENERAL AGGREGATE 5 2,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000
<br /> ICY _...._
<br /> i X POL JR O- r
<br /> I LOC $ ......... ..
<br /> B AUTOMOBILE LIABILITY 071 9714-D30-33 10130/2016 10/30/2017 COMBINED ISINGI E LIMIT 71
<br /> ANY AUTO BODILY INJURY(Per person) s 500,000
<br /> ALL OWNED X SCHEDULED BODILY INJURY(Per accident
<br /> AUTOS AUTOS 5 500,000
<br /> NOPJ-OWNED 1 ....
<br /> 1 I (ROPERTYDAMAGE
<br /> HIRED AUTOS X AUTOS (Per accident) 100,000
<br /> A UMBRELLA LIAR X OCCUR ,I EACH OCCURRENCE $ 1,000,000
<br /> 93-GM-1111-1 0811012016 08/10/2017 OCCURRENCE
<br /> LIAR DE
<br /> i _! CAGGREGATF. �$ 1,000,000
<br /> 1 CEO X-. .RETENTION 5 I 10,000_.._.I .. . _ ....... . . ......... . ....._.-..---- -- . ..,.
<br /> A WORKERS COMPENSATION VVC S1`ATIJ I O/H-
<br /> AND EMPLOYERS'LIABILITY YIN TORY LIMITS` _.- R
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE
<br /> $
<br /> OFFICE/MEMBER CEXCLUDED? E.L.EACH ACCIDENT $ 1,000,000
<br /> Y N I A 93-BX-W682-8 02/20/2016 02/2012017
<br /> (Mandatory In NH) -- - EL.DISEASE EA EMPLOYEE `E 1,000,000
<br /> If yes,describe under 93-CC-C931-6 0212012017 02/20/2018
<br /> 1 I DESCRIPTION OF OPERATIONS below L E.L.DISEASE-POLICY LIMIT $ 1,000,000
<br /> I
<br /> '..DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required)
<br /> Certificate Holder is listed as additional insured on above referenced General Liability Policy
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Orange County SHOULtt-ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE FXPIi TION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> PO Box 8181 ACCO DAN WITH THE POLICY PROVISIONS. ---,,
<br /> Hillsborough, NC 27278
<br /> AUTHORIZE? REPRESENTATIVE ^� ---" 1 ,"I
<br /> /<r-
<br /> ®1988-2010 ACORD CO''0,,ATION. All rights reserved.
<br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD \y~1001486 132849.6 11-15-2010
<br />
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