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DocuSign Envelope ID:41719992-014C-42FB-B112-4FE349CEE5B1 <br /> Ac R© © OATE(MM1DDlYYYY)® CERTIFICATE OF LIABILITY INSURANCE 6/27/2017 <br /> THIS RTIFICATE 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 Kelley Loso <br /> Business Insurers of Carolinas <br /> PHONE FBI: (919)968-4611 FAX <br /> Business (919)968-8991 <br /> BOO Eastowne Drive, Suite 208 kloso@business—insurers.com <br /> PO Box 2536 INSURER(S)AFFORDING COVERAGE NAIC q __ <br /> Chapel Hill NC 27515-2536 INsuRERA:Hamilton Mutual Insurance 14125 <br /> INSURED INSURER B Employers Mutual Casualty 21415 <br /> DISPUTE SETTLEMENT CENTER INC INSURER C: <br /> 302 W WEAVER ST STE A <br /> INSURER D: <br /> INSURER E: <br /> CARRBORO NC 27510-6009 INSURERF: <br /> COVERAGES CERTIFICATE NUMBER:17/1B WC,Bop 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 ADLL SUBR POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER IMMIODIYYYYI (MMIDDIYYYY) LIMITS <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> XJ OCCUR PREMISES A CLAIMS-MADE 300(ES Eaaccurrencal $ 00,000 <br /> 4W54487 6/17/2017 6/17/2018 MEDEXP(Anyonepewan) $ 5,000 <br /> PERSONAL&ADV INJURY <br /> GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 <br /> - <br /> X POLICY 'PROf LOC PRODUCTS-COMP/OP AGG $ 2,000,000 <br /> OTHER: Hired/Borrowed $ 1,000,000 <br /> AUTOMOBILE LIABILITY . COMBINED SINGLE LIMIT $ <br /> (Ea acclden1) <br /> ANY AUTO BODILY INJURY(Per parson) $ <br /> ALL OVVNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS __ AUTOS PROPERTY DAMAGE <br /> HIRED AUTOS AUTOS (Per accident) <br /> NONIJWNED <br /> $ <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTIONS $ pp <br /> WORKERS COMPENSATION - X PER 0TH- <br /> AND EMPLOYERS'LIABILITY YIN STATUTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE - NIA E.L.EACH ACCIDENT $ 100,000 <br /> OFFICER/MEMBER EXCLUDED? <br /> B (Mandatory In NH) 4854407 6/17/2017 6/17/2018 E.L.DISEASE-EA EMPLOYEE $ 100 000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 <br /> DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> jethompson@orangecountync. <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Orange County 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 /> Kelley Loso/KELLL <br /> OE 1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD <br /> INS025 nnramr <br />