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DocuSign Envelope ID: 11591086 - 0989- 4E2D- 8A03- 5E4CDBBE1178
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />PDA7TE(MMIDD/YYYY)
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />02/21 /2018
<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
<br />CONTACT Sherry Whaley, AAI, CRIS
<br />NAME:
<br />Jake A Parrott Insurance Agency Inc
<br />PHONE (252)523 -1041 ac, (252)523 -0145
<br />CC. Ext : No :
<br />E -MAIL swhaley @parrottins.com
<br />2508 N HERRITAGE STREET
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />PO BOX 3547
<br />INSURERA: EMPLOYERS MUTUAL CASUALTY CO
<br />21415
<br />KINSTON NC 28502
<br />INSURED
<br />INSURER B: ACCIDENT FUND INS CO OF AMERICA
<br />10166
<br />INSURERC:
<br />$ 500,000
<br />TILE RESTORATION INC
<br />INSURER D:
<br />$ 10,000
<br />PO BOX 160
<br />INSURER E:
<br />INSURER F:
<br />HOOKERTON NC 28538 -0160
<br />COVERAGES CERTIFICATE NUMBER: 17 18 MASTER 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
<br />LTR
<br />TYPE OF INSURANCE
<br />ADUL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />(MM /DD/YYYY)
<br />POLICY EXP
<br />(MM /DD /YYYY)
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE IX-1 OCCUR
<br />DAMAGE
<br />PREM SESO(Ea occurrence) RENTED
<br />$ 500,000
<br />MED EXP (Any one person)
<br />$ 10,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />A
<br />Y
<br />Y
<br />5D20546
<br />11/07/2017
<br />11/07/2018
<br />GEN'LAGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />X POLICY 1-1 —] ❑ LOC
<br />JECT
<br />PRODUCTS - COMP /OPAGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />(Ea accident)
<br />$ 1,000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />ANYAUTO
<br />A
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />Y
<br />Y
<br />5E20546
<br />11/07/2017
<br />11/07/2018
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />(Per accident)
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />Medical payments
<br />$ 5,000
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />A
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />5J20546
<br />11/07/2017
<br />11/07/2018
<br />AGGREGATE
<br />$ 2,000,000
<br />DED I I RETENTION $
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETOR /PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />N /A
<br />Y
<br />WCV6152738 -0
<br />11/07/2017
<br />11/07/2018
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT
<br />1,000,000
<br />$
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />If Ves, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />1,000,000
<br />$
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />ORANGE COUNTY IS LISTED AS AN ADDITIONAL INSURED AS PERTAINS TO GENERAL LIABILITY, ON A PRIMARY BASIS INCLUDING PRODUCTS & COMPLETED
<br />OPERATIONS, VIAA WRITTEN CONTRACT IN PLACE WITH THIS REQUIREMENT INCLUDED. ORANGE COUNTY IS LISTED AS AN ADDITIONAL INSURED AS
<br />PERTAINS TO
<br />AUTO LIABILITY, VIAA WRITTEN CONTRACT IN PLACE WITH THIS REQUIREMENT INCLUDED. WAIVER OF SUBROGATION IN FAVOR OF ADDITIONAL INSURED
<br />APPLIES
<br />TO GENERALAND AUTO LIABILITYAND WORKER'S COMPENSATION, VIAA WRITTEN CONTRACT IN PLACE WITH THIS REQUIREMENT INCLUDED.
<br />EXCLUDED OFFICERS IN WORKER'S COMPENSATION COVERAGE: DAVID ALBRITTON & CHARLES ALBRITTON III.
<br />CERTIFICATE HOLDER CANCELLATION
<br />@ 1988 -2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ORANGE COUNTY
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />PO BOX 8181
<br />AUTHORIZED REPRESENTATIVE
<br />HILLSBOROUGH NC 27278
<br />�fl) ji Oaw
<br />@ 1988 -2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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