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DocuSign Envelope ID: 134C4810- 3CA5- 4OC8- 9E74- 2AO7D3AECED8 <br />OP ID: KR <br />'4k� ° CERTIFICATE OF LIABILITY INSURANCE <br />0501 � <br />DATE 0710512017 <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 INSURERIS), 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 15 WANED, 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 endarsemen s . <br />PRaaucER <br />CITIZENS INSURANCE AGENCY <br />P 0 BOX 109 <br />HENDERSON, NC 27536 <br />House AccountlJoel T. Cheatham <br />MP Kim Rhodes <br />FAX <br />.2524$2.4061 (AIC. Hal* <br />„ ss, kim nca ent.com <br />aR <br />cusTOMEgIppoCLUBN-2 <br />INSUR a AFFORDING COVERAGE <br />KAIC a <br />INSURSO Club Nova Community, Inc. <br />INSUFMA:PHILADELPHIA INSURANCE CO <br />EACH OCCURRENCE <br />P.O. Box 1346 <br />Carrboro, NC 275104346 <br />INSURERB, <br />X COMMERCIAL GENERAL LIABILITY <br />X CLAIMS#LAOE U OCCUR <br />INSURER(: <br />INSUIUM D <br />0710112017 <br />07/0112018 <br />IROURO E: <br />s 300,00 <br />LIED EXP lAny an <br />INSURER F! <br />X Retro 5113106 <br />COVERAGES CERTIFICATE NUMBER! RFVLRInN 14"URFR- <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 />M�Se <br />TYPEOFINSURANCi <br />Hausa Accou Joel T. Cheatham <br />POLICY NUMUR <br />LIMITS <br />QUIRAL LIABRrrY <br />EACH OCCURRENCE <br />s 11000,0 <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />X CLAIMS#LAOE U OCCUR <br />PHPKI679290 <br />0710112017 <br />07/0112018 <br />PR <br />s 300,00 <br />LIED EXP lAny an <br />3 6,00 <br />X Retro 5113106 <br />PERSOWL3ADVINJURY <br />s 11000100 <br />GENERALAGGREGATE <br />s 3.000,0 <br />GENL AGGREGATE LIMIT APPLIES PER: <br />X POLICY PRO- I 1 LOC <br />PRODUCTS - COMPIOP AGG <br />S 3,000,00 <br />S <br />B <br />AUTOMOBILE LIABILITY <br />X ANY AUTO <br />HPKI672290 <br />0710112017 <br />0710112018 <br />COMBINED SINGLE LOAT <br />IEa I` 1 <br />f 1,000,04 <br />BOOILYINJURY(Perpamm) <br />s <br />ALL OWNED AUTOS <br />BODILY INJURY (Par Kddord) <br />f <br />B <br />SCHEDULED AUTOS <br />X HIRED AUTOS <br />PHPK1679290 <br />0710112017 <br />07/01/2018 <br />PROPERTY DAMAGE <br />(PER ACCIDENT} <br />s <br />B <br />X NON*WNEDAUTOS <br />PHPKIS79290 <br />0710112017 <br />0710112018 <br />IMedPay <br />s 5,00 <br />UMIUIM <br />s 500,00 <br />UMBRELLA UAB <br />OCCUR <br />EACH OCCURRENCE <br />9 <br />AGGREGATE <br />S <br />EXCESS LIAM <br />CLVMS4AAOE <br />DEDUCTIBLE <br />S <br />i <br />RETENTION 3 <br />WORKERS COMPENSATION <br />V,ICSTATU OTH• <br />AND EMPLOYERS' LUIBLM YON <br />AMY PROPRIETORJPARTNEMWECUTNE <br />OFFKMWEMBER EXCLUDED? � <br />N J A <br />E L EACH ACCIDENT <br />f <br />E.L DISEASE .EA EMPLOYEE <br />f <br />(Msndatory InNH) <br />sa to utder <br />er PTION E Ti <br />E.L DISEASE - POLICY LWMT <br />S <br />A <br />Llab. <br />i <br />PHPKIS79290 <br />07101/2017 <br />0710112018 <br />EachClalm 1,000,00 <br />rrof*33ional <br />laims Made <br />I <br />O 6113106 <br />Aggregate 3100010 <br />DESCFJPMN Of OPERATIONS J LOCATIONS I VENICLSS (AMeeA ACORD 10I. AdNtlatsl ponds SshaWk, B mom apses Is mgmindl <br />CERTIFICATE HOLDER CANCFI I ATInm <br />D 1988 -2004 ACORD CORPORATION. All rights reserved. <br />ACORD 26 (2009109) The ACORD name and logo are registered marks of ACORD <br />SHOULD ANY OF THE ABOVE QESCPMW POLICIES BE CANCELLED BEFORE <br />Orange County <br />200 S Cameron St <br />THE WITHTH POLICYPROVISIWNS. BE QELNEREQ IN <br />Hillsborough, NC 27278 <br />AUTOO REP ATNE <br />Hausa Accou Joel T. Cheatham <br />D 1988 -2004 ACORD CORPORATION. All rights reserved. <br />ACORD 26 (2009109) The ACORD name and logo are registered marks of ACORD <br />