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DocuSign Envelope ID: DE9BFO5F-16BB-4A5B-A2E1-D1DBAE265AE3
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<br /> LAWRE-1 OP ID: MG
<br /> ` C ,� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br /> 12/20/2016
<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(les) 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 II
<br /> Thompson-Allen,Inc. NAME: —Phillip Allen _
<br /> p PHONE _-- �FAX-
<br /> P.O.Box 100 (AIC,No,Ext):336-599-2175 -A/c N0j 3 36-599-6932
<br /> Roxboro,NC 27573 EMAIL
<br /> Marcia D.Green ADDRESS: �_- -__- _
<br /> INSURER(SLAFFORDING COVERAGE NAIC k
<br /> INSURER A:Cincinnati Insurance Company 10_677
<br /> •
<br /> INSURED Tommy Lawrence Electrical INSURERs:Cincinnati Casualty Company_. _:28665
<br /> P.O.Box 641
<br /> Roxboro, NC 27573 INSURERC.:. _.____.. ___.
<br /> INSURER D_
<br /> INSURER E: ---_--- --� I —'_
<br /> INSURER F: I
<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 /> LTR TYPE OF INSURANCE INSD LWVD 1 POLICY NUMBER POLICY EFF POLICY EXPO -----
<br /> A X I COMMERCIAL GENERAL LIABILITY ' (_MMIDDIYYYY) POLICY j LIMITS
<br /> —4: _.. 1 EACH OCCURRENCE_ $ 500,000
<br /> ri DAMAGE TO RENTF.t)
<br /> CLAIMS-MADE 1 X �OCCUR EPP 0096783 08/16/2016 08/16/2017 .pRES�)s�s(Ea occurrence) $ 100,000
<br /> I MED EXP(My one person) 1$ 5,000
<br /> •
<br /> J -
<br /> _ I PERSONAL&ADV INJURY i$ 500,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 i
<br /> POLICY I--._ �ECOT L___J LOG PRODUCTS-COMP/OP AGG $ 1,000,000 '
<br /> OTHER: $
<br /> I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000
<br /> A I X 'ANY AUTO EBA 0096783 08/16/2016 i 08/16/2017 BODILY INJURY(Per person) 5
<br /> ALL OWNED 1 SCHEDULED BODILY INJURY Per accident)'$
<br /> 1 AUTOS I AUTOS (
<br /> I NON-OWNED PROPERTY DAMAGE
<br /> j HIRED AUTOS
<br /> AUTOS (Per accident) $
<br /> X UMBRELLA LIAB I X :OCCUR EACH OCCURRENCE $ 5,000,000
<br /> A I EXCESS LIAB I CLAIMS-MADE EPP 0096783 08/16/2016 08/16/2017
<br /> i AGGREGATE $ 5,000,000
<br /> '.DED _j RETENTION$ i $
<br /> Ii WORKERS COMPENSATION I i I I PER I OTH-
<br /> AND EMPLOYERS'LIABILITY YIN STATUTE � ER �._.._
<br /> B 1ANYIPRRPRIETOER/PARLNERE ECUTIVE fN/Aj IEWC 0368238-01 01/01/2016 01/01/20181 EL EACH ACCIDENT $ 100,000
<br /> (Mandatory In NH) 1 I I E.L.DISEASE-EA EMPLOYEE $ 100,000
<br /> If yes,describe under ! -`-'— - —
<br /> DESCRIPTION OF OPERATIONS below i (E.L,DISEASE-POLICY LIMIT $ 500,000
<br /> 1 I I
<br /> I
<br /> r
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> EMAIL: Itaft @orangecountyno,gov
<br /> il
<br /> CERTIFICATE HOLDER _CANCELLATION
<br /> ORANGCG
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> Orange County Government ACCORDANCE WITH THE POLICY PROVISIONS,
<br /> Parks and Recreation
<br /> Lori Taft AUTHORIZED REPRESENTATIVE k
<br /> 200 South Cameron Street M D. r en 0,Hillsborough, NC 27278 "'u� �� `—
<br /> ©1988.2014 ACORD CORPORATION, All rights reserved.
<br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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