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<br /> DocuSi n Envelope ID: 1632E805-38D3-49DF-9836-981006B20F64
<br /> N tire
<br /> CERTIFICATE OF INSURANCE
<br /> DATE ISSUED(MIV1/DD/YY)
<br /> 1
<br /> ,
<br /> . 7/
<br /> ■e Insurance' _THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY— 27717
<br /> Home Office • 100 Erie Insurance Place . Erie,Pennsylvania 16530 • 814 870 2000
<br /> Toll free 1 800 458 0811 • Fax 814 870 3126 • ,,,ww/enernsurance corn
<br /> NAME AND ADDRESS OF AGENCY THE BALLARD AGENCY AGENT'S NO. _ ItaigniV14011 UM IIIIIIII,YAM 1 —
<br /> _ ___ _
<br /> 105 W KING ST J.I1010 D
<br /> „ ça.:_ TACINS.OBAVI PRO•_EATTr&CASuAtil:y Mm PAN Y
<br /> HILLSBOROUGH, NC 27278-2543 Co.:E ERIE INSURANC_E EXCHANGE lot Applicable\
<br /> Ene Indemn0 Uo,,,Attorney-in-Fact in_NY /
<br /> (91 9)732-2 1 58 -"cfla._ENEATURAtic_E_CPMPft QF f■IVV 9 RK
<br /> uo.:G i-LALibmP CI1Y INSui-IANCLA,OM-1-ANY
<br /> .... .,This certificate is issued for Information purposes only and confers
<br /> ______ _
<br /> NAME AND ADDRESS OF NAMED INSURED no rights on the certificate holder. It does not affirmatively or
<br /> Inegatively amend,extend,or otherwise alter the terms, exclusions
<br /> HISTORIC HILLSBORO(JGH and conditions of insurance coverage contained in the policy(ies)
<br /> '.,O?' indicated below,The terms and conditions of the policy(ies)govern
<br /> the insurance coverage as applied to any given situation, Limits
<br /> PO BOX 922 'shown may have been reduced by claims paid.This certificate of
<br /> insurance does not constitute a contract between the issuing
<br /> H1L.LSBOROUG1I,NC 27278 insurer(s), authorized representative or producer and the
<br /> certificate holder.
<br /> .,..i
<br /> This is to certify that policies as indicated by the Policy Number below,are In force for the Named Insured at the time that the Certificate is beta issued,
<br /> CD Mal ' 1 1 •N ; 111 :4h'; 4 __, LIMITS
<br /> TYPE OF INSURANCE POLICY NUMBER
<br /> D. 1GENERAL LIABILITY EACH OCCURRENCE $
<br /> Cl COMMERCIAL GENERAL LIABILITY1 FIRE DAMAGE(Anne FIN) $
<br /> [1]CLAIMS MADE H OCCUR, MED EXP(Any One Pesos)
<br /> E
<br /> I PERSONAL&ADV.INJURY,
<br /> Li ,. __
<br /> GENERAL AGGREGATE $
<br /> GEM_AGGREGATE LIMIT APPLIES PER:, PRODUCTS-COMP/OP AGGI$
<br /> Li..,
<br /> Li POUCT PROJECT LIII LOCI
<br /> pi AUTOMOBILE LIABILITY i 1 BODILY INJURY
<br /> [7] "ANY AUTO"(PtIgERNIP
<br /> I (EACH PERSON)
<br /> , S
<br /> I I BODILY INJURY
<br /> [—._.I OWNED (EACH ACCIDENT) $
<br /> ET HIRED PROPERTY DAMAGE $
<br /> E NON-OWNED BODILY INJURY AND
<br /> ,_, GARAGE PROPERTY DAMAGE
<br /> Li $
<br /> COMBINED
<br /> EXCESS LIABILITY EACH OCCURRENCE $
<br /> E OCCURRENCE AGGREGATE
<br /> $
<br /> r_ , ■ _
<br /> L,,I RETENTION S $
<br /> 1 ,
<br /> E. _,
<br /> , WORKERS COMPENSATION&
<br /> EMPLOYERS LIABILITY Q86 0600392 2/ SrAttgORY
<br /> 6/17 2/6/18 1 BODILY1 ACCIDENT $ 500,000 EACH ACCIDENT
<br /> I NJURY1 DISEASE $ 300,000 POLICY LIMIT
<br /> 1 1
<br /> 1 I BY DISEASE $ 500,000[Acii INELOYEC
<br /> OTHER
<br /> I ,
<br /> 1 I
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
<br /> CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIV
<br /> ERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the
<br /> terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer
<br /> rights to the certificate holder in lieu of such endorsement(s).
<br /> NAME AND ADDRESS OF CERTIFICATE HOLDER
<br /> ORANGE(DUN-FY HUMAN SERVICES AUTHORIZED REPRESENTATIVE
<br /> AGENCY
<br /> PO BOX 8181
<br /> HILLSBOROUGH, N(' 27278 /1 I - ,2
<br /> „,....//2 A )) //, , /
<br /> ,. / . .-,7- ...,-,1..... 4,e /
<br /> E1G6230 8/11 //
<br /> Ruin 1 nf 1
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