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DocuSign Envelope ID:DB9A9EC4-B024-400B-A663-138801D5215E
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<br /> ,�--�"� EMPOINC-01 DMASON .
<br /> A.C°C;0R DATE(MM/DD/YYYY)
<br /> �,_a.∎' 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 I CONTACT `
<br /> RODUCER
<br /> NAME:
<br /> Summers Thompson Lowry,Inc. PHONE
<br /> 100 Europa Drive (A/c,No,Ext):(919)968-4472 1(A/C,No):(919)942-4221
<br /> Suite 571 ADDRESS:info @STLinsure.com
<br /> Chapel Hill,NC 27 51 7-23 93
<br /> .____._.._.._._INSURER(_S)AFFORDING COVERAGE NAIC#._.___._.
<br /> INSURER A_Technology Insurance Company Inc 42376
<br /> INSURED INSURER B:
<br /> Empowerment,Inc. INSURER C
<br /> Delores Bailey
<br /> 109 N.Graham St.#200 INSURER D_
<br /> Chapel Hill,NC 27516-2328 INSURERE:
<br /> INSURER F:
<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 PAID CLAIMS.
<br /> INSRi -__........ .._....-.—_..._.._._
<br /> LTR! TYPE OF INSURANCE ADDL,.SUBR POLICY NUMBER POLICY EFF �,�POLICY EXP LIMITS
<br /> INSR;WVD. (MM/DDlWW)'�.(MM/DD/YYYY)'.
<br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE f X OCCUR INPP1005089 06/16/2017 06/16/2018 DAMAGE TO RENTED
<br /> X PREMISES(Ea occurrence) $
<br /> ■ MED EXP(Any one person) $ 10,000
<br /> 1,000,000
<br /> PERSONAL&ADV INJURY $ _
<br /> J
<br /> _GEN'L AGGREGATE LIMIT APPLIES PER: I (_.GENERAL AGGREGATE $ 3'000'000
<br /> POLICY JECT .__.J LOC PRODUCTS-COMP/OP AGG $
<br /> OTHER: Sex Abuse $ 1,000,000
<br /> AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT 1,000,000
<br /> (Ea.accident) $-----------------
<br /> ANY AUTO NPP1005089 06/16/2017'.06/16/2018 BODILY INJURY(Per person).,.,._._$__..__
<br /> OWNED SCHEDULED
<br /> AUTOS ONLY 1 AUTOS i; BODILY INJURY(Per accident) $_____..._,,,.__,_„____
<br /> X AUTOS ONLY X NON-OWNED ONLY (Per accidentDAMAGE $
<br /> $
<br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $
<br /> EXCESS LIAB CLAIMS-MADE( AGGREGATE $
<br /> DED RETENTION$ ', $
<br /> A WORKERS COMPENSATION PER IOTH-
<br /> AND EMPLOYERS'LIABILITY y/N TWC3634138 : 06/16/2017' X STATUTE I JER.,_-..___ ___
<br /> 06/16/2018 500,000
<br /> ANY PROPRIETORR R/EXECUTIVE E.L.EACH ACCIDENT $
<br /> EXCLUDED?
<br /> OFFICER/MEMBER EXCLUDED? N/A
<br /> (Mandatory in NH) ---- E.L.DISEA_SE_-EA EMPLOYEE $ 500,000
<br /> If yes,describe under 500,000
<br /> DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $
<br /> Prof Liability NPP1005089 11 06/16/2017 06/16/2018 Occurrence 1,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional 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 AUTHORIZED REPRESENTATIVE
<br /> 3 Cfnn t ft Swv nr,.w 5
<br /> ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD
<br />
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