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Jul. 12. 2011 10:01AM TYSON INS No. 0283 P. 1 opID:C1= <br /> CERTIFICATE OF LIABILITY INSURANCE —DATE 0711 1201 YY} <br /> 07112!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 pollcy(fes)must be endorsed. If SUBROGATION IS WAIVED,subject to <br /> the teems 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 /> Tyson InsurBnob Servlcbs,Inn. PHONE FAx <br /> 2609 N Duke St Suite 102 a/e Y-): <br /> P.0.Box 15734 AoDRE, <br /> Durham,NC 2T70A- P DU ER NANTCAF <br /> Carmon C.Ellis c <br /> INSU AFFORDING COVERAGE NAIC0 <br /> INSURED Nantucket Cafe,Inc, INSURERA:The Harford Mutual Ins.Co. <br /> P.0.Box 2655 ` INSURER e I First Benefits Insurance Co. 49422 <br /> Chapel Hill,NC 27515 INSURFRC:Pro r9SSive Insuraance Co. <br /> INSURER D i <br /> INSURER E <br /> INSURER F! <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS 1S 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 6E 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 TYPE OF INSURANCE u EFF P u , <br /> PCLICYNUMEER MM C DD LIMITS <br /> ra.ENERAL L LOAlUrY <br /> EAGNOCCURRENCE S 1,000,00 <br /> A X GOMMERGUL GENERAL UA9amI 8175675 0710412017 07104I2018 PREM E E� <br /> OuLwancal S 6300,00 <br /> I <br /> CMMS'we f—AVI OCCUR MEO W(Any Om Pdrw) S 5,00 <br /> PERSONAL&AWINJURY s 1,000,00. <br /> GENERA.AGGREGAru S 2,000,00 <br /> GUM AGGREGATE LIMIT APPLIES PWt PRODUCTS.COMP/OPAGG S 1,000,00 <br /> WuCY PRO- LOC S <br /> AUTON06LLE UMLAY COMBINED SINGLE LIMIT $ 1,000,00 <br /> C X ANYAUTO 0278368-1 11119/2016 11/19/2017 BODILY INJURY(PerPVlsvn) S <br /> ALL OWNED AUTOS <br /> SCHEDULEDAUY05 BODILY INJURY(PofAcdcleAq $ <br /> PROPERTY OAMAOE S <br /> X HIRED AUTOS (PER ACCIDENT) <br /> X NON-OWNEDAVTOS S <br /> S <br /> UMSREUAUAU X OCCUR EACH 9CCURRENCE s 1,000,00 <br /> DICESSUAB X CWM8-�MDE AGG'Wr- S <br /> A 7974944 i 074//02017 0714/2018 <br /> DEDAICTIDLE ,.:€:�;: y <br /> RETENTION S Y 3 <br /> WORKERS CONPENSAYIDN WC STATU, X I"PR EMPLOYERS'LLwLIYY <br /> B ANY PROPRItYORIPARTNERA7tECunvE'Y/N 0 441-2017 06/Oi/2017 06/01/2018 E,L EACH ACCIDENT 5 1,000,00 3 <br /> OF CC�ry k ,EXCLUDED? � NIA <br /> Kyy,Mary ht H) E.L.DISEASE•FA EMPLOYEE S 1,000,()0 j <br /> 0E6CRIFnONOFOPERA11098t f. E.L.DISWE-POLICY LIMIT S 1,000,00 <br /> OESCMMON OF OPERATIONS I LOCATIONS I VEIUCLIM(A non AOORD 101,AddlOvvel Rvmadu gdwdW*.If more epAce Is"Ired) <br /> 1101S#1� UGADX6A1116955&2010 GMC S#1GTUGADX8A1122708,$1000 Comp o Ive <br /> CERTIFICATE HOLDER CANCELLATION <br /> SENICEN - <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORS <br /> Senior Center Of Orange County THE EXPIRATION PATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> 9 ty ACCORDANCE WITH THE POLICY PROVISIONS. <br /> fax#919-732-2239 <br /> Attn:Isabella AUTHORIZED REPREWr <br /> 103 Meadowlands Dr. Carmon C.Ellis <br /> Hillsborough,NC 27278 <br /> 0 1988-2009 ACORD CORPORATION. Ali rights reserved. <br /> ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD <br />