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DocuSign Envelope ID:928D532F-8E85-438B-A45F-55FACC1 BCOOA <br /> AC©R©® CERTIFICATE OF LIABILITY INSURANCE DATE(M.1,'GD,'YYYY) <br /> 08/08/2017 <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 tJAh9E: Sam Testerman <br /> Triad Insurance Associates IPHONE n,Etl>: 919-663-0303 FAX N©)_( 919)663 0454 <br /> 112 South Chatham Avenue ADDRESS: triadinsurance©yahoo.com <br /> PO Ba 512 INSURER(S)AFFORDING COVERAGE NAICu <br /> Siler City NC 27344 INSURER A: Mesa Underwriters Specialty 00000 <br /> INSURED INSURER B: Evanston Insurance Company <br /> Wayne Oldham&Son House Moving INSURER C <br /> 12901 Siler City-Glendon Rd. INSURER D: <br /> INSURER E: <br /> Bear Creek NC 27207 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 BY PAID CLAIMS. <br /> INSR TYPE ADDLSUBR POLICY EFF POLICY EXP LIMITS <br /> LTR Irsr W�.VD POLICY NUMBER (MMIDDtYYYY) (MMIDD1YYYY) <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1000000 <br /> CLAIMS-MADE OCCUR. DAMAGE TO RENTED <br /> PREMISES(Eaoccurrence) $ 100000 <br /> MED EXP(Any one person) $ 1 000 <br /> A N N MP01 32007000034 01/20/2017 01/20/2018 PERSONAL&ADVINJLIRY $ 1000000 <br /> GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000000 <br /> POLICY PRO-JECT LOC PRODUCTS-COMPIOPAGG $ 2000000 <br /> OTHER $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OVNJED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY (Per accident) <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY STATUTE ER <br /> YIN <br /> ANY PROPRIETOR;PARTNER!EXECUTIVE E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBER.EXCLUDED? N f A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> Cargo 100.000 <br /> B N N IM5536103 08/29/2016 08/29/2017 <br /> DESCRIPTION OF OPERATIONS?LOCATIONS?VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> house mover <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Orange County ACCORDANCE WITH THE POLICY PROVISIONS. <br /> PO Box 8181 <br /> AUTHORIZED REPRESENTATIVE <br /> Hillsborough NC 27278 <br /> Fax: Email:jethompson©orangecountync.gov © 1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br />