|
DocuSign Envelope ID: 16604FCD -37FD- 4038- 8DOC- 86OA7AA63162 ATI411VA -1 Op in. f_R
<br />,d 4c CERTIFICATE OF LIABILITY INSURANCE
<br />`�
<br />DATE (MM /DDmvY)
<br />12/26/2017
<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 have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER 919 - 556 -3698
<br />Hartsfield & Nash ency, Inc.
<br />Post Office Box 110
<br />CONTACT Lorie Borrelli, CIC, AAI
<br />NAME:
<br />PHONE 919 - 556 -3698 FAX 919- 556 -8758
<br />(A/C, No, Ext): (A/C, No):
<br />ADDRESS:
<br />Wake Forest, INC 27588
<br />Lorie Borrelli, CIC, AAI
<br />22SBAVF0089
<br />12/01/2017
<br />12/01/2018
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA: Hartford Casualty Ins Co.
<br />29424
<br />300,000
<br />$
<br />INSURED 5th Wall Building Diagnostics
<br />INSURER B: Lexington Insurance Co.
<br />19437
<br />Consultants LLC
<br />PERSONAL & ADV INJURY
<br />9601 Bailywick Rd
<br />INSURER C:
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY [::] PR T [::] LOC
<br />OTHER:
<br />INSURER D:
<br />$ 4,000,000
<br />Raleigh, INC 27615
<br />INSURER E:
<br />INSURER F:
<br />A
<br />AUTOMOBILE
<br />COVERAGES CERTIFICATE NUMRFR- REVISION NUMRFR-
<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
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUBR
<br />POLICY NUMBER
<br />POLICY EFF
<br />M DD
<br />POLICY EXP
<br />M DD
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE � OCCUR
<br />Business Owners
<br />22SBAVF0089
<br />12/01/2017
<br />12/01/2018
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence)
<br />300,000
<br />$
<br />MED EXP (Any one person)
<br />$ 10,000
<br />PERSONAL & ADV INJURY
<br />$ 2,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY [::] PR T [::] LOC
<br />OTHER:
<br />GENERAL AGGREGATE
<br />$ 4,000,000
<br />PRODUCTS - COMP /OP AGG
<br />$ 4,000,000
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />22SBAVF0089
<br />12/01/2017
<br />12/01/2018
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,000,000
<br />$
<br />BODILY INJURY Per person)
<br />$
<br />BODILY INJURY Per accident
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />A
<br />X
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />22SBAVF0089
<br />12/01/2017
<br />12/01/2018
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />AGGREGATE
<br />$
<br />DED X RETENTION$ 10,000
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />ANY PROPRIETOR/PARTNER/EXECU I IVE ❑
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />N / A
<br />PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$
<br />E.L. DISEASE - EA EMPLOYEE
<br />$
<br />E.L. DISEASE - POLICY LIMIT
<br />B
<br />Professional Liab
<br />064988620
<br />02/12/2017
<br />02/12/2018
<br />Per Occur
<br />Aggregate
<br />1,000,000
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />CERTIFICATE HOLDER CANCELLATION
<br />ORAN818
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />Orange County
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />PO Box 8181
<br />Hillsborough, NC 27278
<br />AUTHORIZED REPRESENTATIVE
<br />ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
|