Orange County NC Website
DocuSign Envelope ID:2EE4F1 CD-7746-4100-8875-349083396637 <br /> POECL-1 OP ID: LP <br /> ACORD DATE(MM/DD/YYYY) <br /> CERTIFICATE OF LIABILITY INSURANCE 10/19/2017 <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 Christopher Ives Rubish <br /> High&Rubish Insurance Agency PHONE FAx <br /> P.O.Box 3040 (A/C,No,Ext):919-913-1144 (A/C,No);919-913-1155 <br /> 6015 Farrington Rd.Ste 101 E-MAIL chrisr hi handrubish.com <br /> Chapel Hill,NC 27517 ADDRESS: 9 <br /> Jeffrey A.Rubish INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A:Owners Insurance Company 32700 <br /> INSURED Clark Poe Construction Inc INSURER B:Builders Mutual Insurance Co <br /> 134 Granger Rd <br /> Chapel Hill,NC 27516-4503 INSURER C: <br /> INSURER D <br /> INSURER E: <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 BY PAID CLAIMS. <br /> INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS <br /> LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) <br /> GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> A X COMMERCIAL GENERAL LIABILITY 35228565 02/18/2017 02/18/2018 DAMAGE TO RENTED 300,000 <br /> PREMISES(Ea occurrence) $ <br /> CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 <br /> PERSONAL&ADVINJURY $ 1,000,000 <br /> GENERAL AGGREGATE $ 3,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 <br /> POLICY PRO- <br /> JECT $ <br /> JECT <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT . 500,000 <br /> (Ea accident) <br /> A X ANY AUTO 5063197100 02/18/2017 02/18/2018 BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS AUTOS — <br /> NON-OWNED PROPERTY DAMAGE $ <br /> HIRED AUTOS AUTOS _PERACCIDENT) _ <br /> UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION X TWTATIU-S 0T - <br /> AND EMPLOYERS'LIABILITY <br /> Y/N <br /> B ANY PROPRIETOR/PARTNER/EXECUTIVE 0067527-2017A 08/06/2017 08/06/2018 E.L.EACH ACCIDENT $ 500,000 <br /> OFFICER/MEMBER EXCLUDED? N/A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> ORANG-1 <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> ORANGE COUNTY ENVIRONMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> AGRICULTURE, PARKS AND ACCORDANCE WITH THE POLICY PROVISIONS. <br /> RECREATION <br /> PO Box 881 AUTHORIZED REPRESENTATIVE S �, (� <br /> HILLSBOROUGH, NC 27278 " � 0.,fix <br /> ©1988-2010 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD <br />