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DocuSign Envelope ID:7514D094-C724-420A-8848-E6072006DEC2 DATE
<br /> 11114.,q16.19,416,1Cor CERTIFICATE OF LIABILITY INSURANCE 8/14/2017
<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 be endorsed.If SUBROGATION IS WAIVED,subject to
<br /> the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
<br /> certificate holder in lieu of such endorsement(s).
<br /> PRODUCER Contact Name: Larry Cossio
<br /> Cossio Insurance Agency Phone (864)688-0121 Fax
<br /> PO Box 5987 (NC,No,Ext): (A/C,No):
<br /> Greenville,SC 29606 E-Mail: tammy @cossioinsurance.com
<br /> (864)688-0121 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURED INSURER A: NATIONWIDE MUTUAL INS CO 23787
<br /> Inflate-a-Party.com,INC. INSURER B: Berkley Life&Health Insurance Company 64890
<br /> 11781 US Highway 64
<br /> Apex,NC 27523 INSURER C:
<br /> INSURER D:
<br /> INSURER E:
<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 OF POLICY ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br /> LTR INSR WVD (MM/DD/YY) (MM/DD/YY)
<br /> X COMMERCIAL GENERAL LIABILITY Products&Completed Operations $1,000,000
<br /> ❑❑ CLAIMS MADE OCCUR Damage to Premises Rented to You $300,000
<br /> General Agg(Other than Products-C $5,000,000
<br /> ❑ Each Occurrence $1,000,000
<br /> A ❑ X FWC0000028012600 4/2/2017 4/2/2018 Personal&Advertising Injury $1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER Legal Liability to Participants $1,000,000
<br /> X POLICY ❑PROJECT ❑LOC Professional Liability(for Event Plann $1,000,000
<br /> Participant Accident-Excess Medical $10,000
<br /> ❑OTHER: Deductible None
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
<br /> ❑ ANY AUTO (Ea accident)
<br /> ❑
<br /> ALL OWNED ❑ SCHEDULED BODILY INJURY(Per Person) $
<br /> AUTOS AUTOS
<br /> HIRED AUTOS NON-OWNED BODILY INJURY(Per accident) $
<br /> ❑AUTOS
<br /> ❑ ❑ PROPERTY DAMAGE $
<br /> (Per accident)
<br /> ❑ UMBRELLA LIAB ❑ OCCUR
<br /> ❑ EXCESS LIAB ❑ CLAIMS-MADE
<br /> ❑ DED ❑ RETENTION$
<br /> WORKERS COMPENSATION PER OTH-
<br /> AND EMPLOYERS'LIABILITY STATUTE ER
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N
<br /> OFFICER/MEMBER EXCLUDED? N/A
<br /> (Mandatory in NH)
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below
<br /> Accident Medical Deductible $100
<br /> Benefit Period 52 weeks
<br /> g Accident Medical PAI L01200R024702 4/2/2017 4/2/2018 Benefit Maximum $500,000
<br /> Applies During per Covered Accident
<br /> Applies To Death&Dismemberment Benefits only
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
<br /> Party Equipment Rentals Operations located at 11781 US Hwy 64 Apex,NC 27523.Certificate Holder is listed as additional insured per form CG2011.The certificate holder is
<br /> added as an additional insured,but only for liability caused,in whole or in part,by the acts or omissions of the named insured
<br /> Amusement devices on file with the company for special event(s)dated 08/19/2017,located at 195 Torain Street,Hillsborough,NC 27278.Coverage is excluded for Mechanical
<br /> Bull,Rockwall,Trackless Train
<br /> CERTIFICATE HOLDER: CANCELLATION
<br /> Orange County Government SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> P.O.Box 8181 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
<br /> Hillsborough,NC 27278 ACCORDANCE WITH THE POLICY PROVISIONS. ❑ `
<br /> AUTHORIZED REPRESENTATIVE
<br /> ©1988-2014 ACORD CORPORATION.All rights reserved.
<br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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