2017-514-E AMS - The Water Specialist to install water filtration system to existing well

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DocuSign Envelope ID: 1 DE4E8C1-837F-42D1-B56B-39F84301386C �® AC DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 8/23/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER =CI- Perry Miller Business Insurers of Carolinas (a//C,NNo,Ext): (919)968-4611 FAX No): (919)968-8991 800 Eastowne Drive, Suite 208 ADDRIESS:pmiller @business-insurers.com PO Box 2536 INSURER(S)AFFORDING COVERAGE NAIC# Chapel Hill NC 27515-2536 INSURERA:Penn National Security 32441 INSURED INSURERB:PA National Mutual Cas Inc 14990 The Water Specialist, DBA: JC Johnson Plumbing INSURERC:Technology Insurance Company 42376 & Septic Service INSURER D: 608 Cornerstone Court INSURER E: Hillsborough NC 27278 INSURER F: COVERAGES CERTIFICATE NUMBER:17-18 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR CX9 0728273 DAMAGE TO RENTED PREMISES(Ea occurrence) $ 500,000 3/29/2017 3/29/2018 MED EXP(Any one person) $ 10,000 PERSONAL&ADVINJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Subcontractor Limit $ 100,000 AUTOMOBILE LIABILITY AX9 0728273 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED X AUTOS X AUTOS 3/29/2017 3/29/2018 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) $ Uninsured motorist combined $ 1,000,000 X UMBRELLA LIAB X OCCUR Umbrella Follows Form Auto EACH OCCURRENCE $ 2,000,000 B EXCESS LIAB CLAIMS-MADE GL & WC AGGREGATE $ 2,000,000 DED RETENTION$ UL9 0728273 3/29/2017 3/29/2018 $ WORKERS COMPENSATION TWC3612232 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? y C (Mandatory in NH) 3/29/2017 3/29/2018 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) REFERENCE JOB:Cedar Grove Park - 5800 Hwy 86 N CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Patty Miller/PATTY 0 21- G ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401