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DocuSign Envelope ID:AD251 D55-21 B9-4E45-B277-2076A6D0468D <br /> AC R D CERTIFICATE OF LIABILITY INSURANCE ' DATEIMM/DO/YYYY) <br /> kcwww■ 11/13/2017 <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 INSUREI (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 I <br /> Cothran Insurance NAME: Leah Spence <br /> 423 Laxton Road (Ara,ONE No.Fti)•434-239-2886 1 fa No);434-237-0085 <br /> Lynchburg VA 24502 E-MAIL cois @cothraninsurance.com <br /> INSURER(S)AFFORDING COVERAGE NAIC 0 <br /> INSURERA:Nationwide Mutual Insurance Co 23787 <br /> INSURED FOURS-1 INSURER B:Nationwide Mutual Fire Ins Co 23779 <br /> FOUR STAR PETROLEUM INSURER C:Accident Fund <br /> SERVICES INC INSURER D:Homeland Ins Co of NY <br /> 1119 Beaumont Dr <br /> ROANOKE VA 24019 INSURERE: <br /> _INSURER F: I <br /> COVERAGES CERTIFICATE NUMBER:700568704 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 ADM SUER POLICY EFF POUCY EXP <br /> LTR HOD WVD POLICY NUMBER IMM/DD/YYYYI (MM/DDIyYYY) LIMITS <br /> A x COMMERCIAL GENERAL LIABIUTY Y Y ACPGL02446156994 5/15/2017 5/15/2018 EACH OCCURRENCE I $1,000,000 <br /> IDAMAGE TO RENTED <br /> CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 <br /> MED EXP(Any one person) $5,000 <br /> PERSONAL&ADV INJURY $1 000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I $2,000,000 <br /> X POLICY JECT E. LOG PRODUCTS-COMP/OP AGG $2,000,000 <br /> OTHER: I $ <br /> A AUTOMOBILE LIABILITY ACPBA2446156994 5/15/2017 5/15/2018 {Ea aNaeml INGLE LIMIT I $1,000,000 <br /> X ANY AUTO BODILY INJURY(Per person) I S <br /> ALULrQ_WNEO ASCUIHEDULED BODILY INJURY(Per accident)' $ <br /> HIRED AUTOS NON-OWNED PROPERTY DAMAGE <br /> AUTOS (Per accident) $ <br /> i $ <br /> B X UMBRELLA UAB X OCCUR ACPCAF2436156994 5/15/2017 5/15/2018 EACH OCCURRENCE $3,000,000 <br /> EXCESS LIAR CLAIMS-MADE <br /> AGGREGATE I,$ <br /> DED I RETENTIONS $ <br /> C WORKERS COMPENSATION WCV6100948 4/1/2017 4/1/2018 X I Mum 1 0TH- <br /> AND EMPLOYERS'UABIUTY Y/N UTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE I E.L.EACH ACCIDENT I $1,000,000 <br /> OFFICER/MEMBER EXCLUDED? N/A <br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 <br /> It yes,desaibe under <br /> DESCRIPTION OF OPERATIONS below E DISEASE-POUCY LIMIT I $1,000,000 <br /> D Contractors Pollution 793-00.46-59-0001 5/15/2017 5/15/2018 Occurrence 1,000,000 <br /> Aggregate 11,000,000 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached I/more apace Is required) <br /> The certificate holder is an additional insured and/or waiver of subrogation applies in favor of holder if required by written contract prior to loss <br /> via endorsement CG7331 in regards to General Liability. <br /> Orange County, officers,official agents and employees are additional insureds with respect to GL as required by written contract via <br /> endorsement CG7331.We will endeavor to provide 30 days advance notice for cancellation or material change in coverage. <br /> CERTIFICATE HOLDER <br /> CANCELLATION <br /> I <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Orange County Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 200 South Cameron St <br /> Hillsborough NC 27278 A.UTTHORIZED/ I$REPRESEN ATIVE <br /> I1?Ms • <br /> I �� <br /> ©1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <br />