2018-053-E AMS - HM Kern Passmore Addition

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DocuSign Envelope ID: 313DA256 -1 EDE- 4396- A716- 4C53B809027E ACaR °� CERTIFICATE OF LIABILITY INSURANCE L� DATE(MMIDDIYYYY) 1/12/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 1NSUREII AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER SIA Group, Inc. 827 Gum Branch Road Jacksonville NC 28540 CONTACT Lindsay Lutz awo a FAx vc E•r : 910-478-3373 Arc No : 910- 455 -7481 ADDRESS: certs sia rou .corn - INSURER(S), AFFORDING COVERAGE NAIL # EACH OCCURRENCE 51,000,000 INSURER A:. Selective Ins. 12572 _ _ INSURED 17724 H.M. Kern Corporation P.O. Box 19424 INSURER 6: Builders Mutual Ins Co 1 0844 INSURER C: Peerless 24198 Greensboro NC 27419 -9424 INSURER D: INSURER E INSURER F: PERSONAL &ADV INJURY $1,000,000 COVERAGES CERTIFICATE NUMBER: 1019795952 REVISION NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD 506E ; POLICY EFF POLICY EXP POLICY NUMBER MMIDDIYYYY ) (MMI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F OCCUR S22594220D 7!112017 7/112018 EACH OCCURRENCE 51,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence ) $ 500,000 MED EXP (Any ane person) $ 15.0D0 PERSONAL &ADV INJURY $1,000,000 GEWL AGGREGATE LIMIT APPLIES PER: PRO- GENERAL AGGREGATE $ 2,000,000 PRODUCTS- COMPlOPAGG $2,000,000 POLICY -' U LOC $ OTHER: A AUTOMOBILE LIABILITY }XA ANY AUTO 5225942260 71112017 71112018 COMBINED SINGLE LIMIT Ea accident $ 1,00o, 000 BODILY INJURY (Per person) $ OWNED F SCHEDULED AUTOS ONLY AUTOS r BODILY Paraccident ( ) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident 5 5 -- A X UMBRELLA LIAB OCCUR S225IJ42200 7!112017 7/112018 EACH OCCURRENCE 10,000,000 AGGREGATE _$ $ 10,000,006 EXCESS LIAB CLAIMS -MADE DED I X RETENTION $ in nnn I� $ a WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN_. VVCP1053448 71112017 71112018 PER 1 7 OT 1_ STATUTE ER E.L. EACH ACCIDENT $ 500.000 ANYPROPRIETOR/PARTNERIEXECU 11— OFFICERIMEMBEREXCLUDED? ❑ INIAi E.L. DISEASE - EA EMPLOYEE $ 50D.000 (Mandatory in NH) If yes., describe under E.L. DISEASE - POLICY LIMIT $ 50o,o60 DESCRIPTION OF OPERATIONS below _ C LeasedlRentedEquipment Builders Risk E I IM6980116 711/2017 71112018 Limit 500,000 Anyone Project 10,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101, Additional Remarks Schedule, maybe attached if more space is required) RE: Jerry M Passmore Center Addition & Renovation. Certificate holder is additional insured for general liability and automobile liability. Waiver of subrogation in favor of the additional insured applies. CERTIFICATE HOLDER CANCELLATION Orange County PO Box 8181 Hillsborough NC 27278 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY' PROVISIONS. AUTHORIZED REPRESENTATIVE i 1�;L' U 15t58 -ZU15 AGURD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD