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DocuSign Envelope ID: DB9A9EC4-B024-400B-A663-138801D5215E <br /> 31 <br /> EMPOINC-01 DMASON <br /> AC©/GZ© DATE(MMIDDIY'YYY) <br /> CERTIFICATE OF LIABILITY INSURANCE 07/18/2017 <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 CONTACT ........ ._.._ _. .. <br /> WAME:_........ <br /> Summers Thompson Lowry,Inc. PHONE FAx <br /> 100 Europa Drive (Arc ,No Eat): 91119)968-4472 (Ave,No):(919)942-0221 <br /> Suite 571 iAII Alss info@STUnsure.com <br /> Chapel Hill,NC 27517-2393 <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> B SL)RERA Technology Insurance C©m,pany Inc 42376 <br /> INSURED INSURER B ......._ <br /> Empowerment,Inc. INSURER C <br /> Delores Bailey <br /> 109 N.Graham St.#200 i INSURER 0 <br /> Chapel NIB,NC 27516-2328 INSURER E: I <br /> _.. ._ I 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 /> INSR ADDL SUER POLICY EFF POLICY EXP..... <br /> TYPE OF INSURANCE . ...WVD .__.. 'euu LIMITS.. _..... <br /> . POLICY NUMBER <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,0001 <br /> CLAIMS.MADE. X,OCCUR X NPP1 005089 06/16/2017 06/16/2018 PREMI DAMAGE TO RENTED <br /> 10,000 <br /> .... 1 <br /> GEN"L AGGREGATE Ltlhb P RSONAL& !ADM INJURY S 1,000,000 <br /> �1 IT APPLIES PER' ! I GENERAL AGGREGATE $ .....,3,000,000 <br /> POLIICY I J'CT LOC 1 P R ODUCTS-COMP/OP AGG .$ <br /> OTHER x Abuse 1,000 000 <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,0001 <br /> (f: EPGIdEPI) $ <br /> ANY AUTO NPP1005089 ` 06/16/2017 06/16/2018 BODILY INJURY(Per J.aersan) !$ <br /> OWNED SCHEDULED <br /> AUTFFOS ONLY AUTOS BODILY INJURY(Per accWsnty $ <br /> X AtiJTOS ONLY X ;AUNOS ONLY PROPERTY DAMAGE <br /> __.! 1 I $ <br /> UMBRELLA L�IAB OCCUR 1 PALM'OCCURRENCE ,_,S„e..,. <br /> d <br /> EXCESS LIAB CLAIMS-MADE „ .. <br /> S <br /> r .� I S DEO I RETENTIONS <br /> A WORKERS COMPENSATION PER 0TH• <br /> AND EMPLOYERS"LIABILITY X_ $TA7LlTlE<; I <br /> D TWC3634138 06116/2017 06/16/2018 <br /> ANYIeERMIEMTERIPARTNER©a ECUTwE I N r A. E L EACH ACCIDENT 500,000 <br /> DESCRIPTION under PERATIONS below E L DISEASE mm POLICY LITMITE 500,000 <br /> ((Mandatory In NH <br /> 500,000 <br /> Prof Liability NPP1005089 06/16/2017 06/16/2018 Occurrence 1,000,000 <br /> I <br /> 1 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IIACORD 101,Addltlonal Remarks Schedule,may be attached if more space is required) <br /> UniFi Equipment Finance,Inc.and its assignors&assignees are additional insured as respects written contract.Contract Number 175024-0002;Xerox <br /> WorkCenre 7225 Trade up for Lease 175024-01 valued$18,015.15 <br /> CERTIFICATE HOLDER .... CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> UniFi Equipment Finance,Inc.ISAOA/ATIMA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> c/o American Lease Insurance <br /> 654 Amherst Road, _______ <br /> Sunderland,MA 01375 I AUTHORIZED REPRESENTATIVE <br /> ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />