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DocuSign Envelope ID: COB5AOFE- D52E- 4B9D- B7EA- 62DB83FFE546
<br />�® CERTIFICATE OF LIABILITY INSURANCE
<br />°AT DIYYYY)
<br />TYPE OF INSURANCE
<br />()2212512126f201 8
<br />THIS CERTIFICATE 1S 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 patty Miller
<br />NAME
<br />Business Insurers of Carolinas
<br />a ON o ext : (919) 968 -4511 FAIR N ®, (919) 968 -8991
<br />800 Eastowne Drive, Suite 208
<br />E -MAIL pmilfer @business- insurers.com
<br />ADDRESS:
<br />PO BOX 2535
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIL #
<br />Chapel Hill NC 27515 -2536
<br />INSURER A , Penn National Security
<br />32441
<br />INSURED
<br />INSURER B : PA National Mutual Gas Inc
<br />14990
<br />Eastern Turf Maintenance Inc,
<br />INSURER c : Accident Fund National Ins Co
<br />12305
<br />3305 Anvil Place
<br />INSURER D:
<br />$ 2,000,000
<br />INSURER E:
<br />$ 2,000,000
<br />Raleigh NC 27603
<br />INSURER F;
<br />AUTOMOBILE LIABILITY
<br />X ANYAUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED NON -OYMED
<br />AUTOS ONLY AUTOS ONLY
<br />19
<br />COVERAGE$ CERTIFICATE NUMBER: 18 -19 REVISION NUMBER:
<br />THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAYBE 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 />ALPLPL
<br />INSD
<br />hLIUM
<br />'WVD
<br />POLICY NUMBER
<br />1. R5LICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MMIDDIYYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIALGENERALLIABILITY
<br />CLAIMS -MADE ®OCCUR
<br />CX90727704
<br />0311512018
<br />03/15/2019
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />PREMISES -Ea occurraffa
<br />$ 100, ()00
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL &ADVINJURY
<br />$ 1,000,0()0
<br />GEN'LAGGREGATE LIMITAPPLIES PER:
<br />X POLICY O PRO- ❑ LOC
<br />JECT
<br />OTHER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />PRODUCTS AGG
<br />$ 2,000,000
<br />$
<br />A
<br />AUTOMOBILE LIABILITY
<br />X ANYAUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED NON -OYMED
<br />AUTOS ONLY AUTOS ONLY
<br />19
<br />AX90727704
<br />03/15/2018
<br />0311512019
<br />COMBINED SINGLE LIMIT
<br />Ea awdeN
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />BODILY INJ U RY Per aceldent
<br />( )
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />Endorsements
<br />$
<br />B
<br />X
<br />UMBRELLA LIAR
<br />EXCESS LIAR
<br />xi
<br />OCCUR
<br />CLAIMS-MACE
<br />UL90727704
<br />03/15/2018
<br />03115/2019
<br />EACH OCCURRENCE
<br />$ 3,000,000
<br />AGGREGATE
<br />$ 31000,000
<br />DED RETENTION $ 101()00
<br />X
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETORIPARTNERIEXECUTIVE YIN
<br />OFFICERIMEMBEREXCLUDED?
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESC
<br />DESCRIPTION N DF OPERATIONS below
<br />NIA
<br />WCV &1242,00
<br />OW1512018
<br />0311512019
<br />�,,r
<br />/\ ST TUTS ERH
<br />E.L. EACH ACCIDENT
<br />$ 1,000,() ()0
<br />-
<br />E. L. DISEASE - EA EMPLOYEE
<br />$ 1.000,000
<br />E, L. DISEASE - POLICY LIMIT
<br />S 1,000'000
<br />A
<br />LeasedlRented Equipment
<br />GX9 0727704
<br />()311512018
<br />03{1512019
<br />50,000ACV
<br />$500 deductible
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
<br />J_1dLy�� +tllL ►li
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES RE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN
<br />Orange County Parks & Rec Robert Robbins ACCORDANCE WITH THE POLICY PROVISIONS.
<br />5800 Hwy 86 N
<br />AUTHORIZED REPRESENTATIVE
<br />Cedar Grove NC 27278
<br />0 1988 -2015 ACORD CORPORATION, All rights reserved.
<br />ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
<br />
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