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DocuSign Envelope ID: B49FB256 -4ADF- 4759- AF63- 134AD44FC239
<br />� CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (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 />2/19/2018
<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
<br />NAME: Lindsay Lutz
<br />SIA Group, Inc.
<br />827 Gum Branch Road
<br />PHONE FAX
<br />(A/C. No Ext : 910- 478 -3373 A/C No): 910- 455 -7481
<br />ADDRIESS: certs@siagroup.com
<br />Jacksonville NC 28540
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />5/22/2018
<br />INSURERA: Pennsylvania National Mutual Casualty
<br />$1,000,000
<br />INSURED 720
<br />INSURER 13: Builders Mutual Ins Co
<br />10844
<br />Century Slate Company
<br />Kodiak Developments, LLC
<br />INSURER C,
<br />$100 '000
<br />INSURER D:
<br />MED EXP (Any one person)
<br />1310 E. Cornwallis Rd.
<br />INSURER E:
<br />Durham NC 27713
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 861427652 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 />ADDL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICYNUMBER
<br />POLICY EFF
<br />MM /DD /YYYY
<br />POLICY EXP
<br />MM /DD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />Y
<br />CL90640065
<br />5/22/2017
<br />5/22/2018
<br />EACH OCCURRENCE
<br />$1,000,000
<br />CLAIMS -MADE OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$100 '000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY ❑X PRO- ❑ LOC
<br />JECT
<br />PRODUCTS - COMP /OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />Y
<br />Y
<br />AU90640065
<br />5/22/2017
<br />5/22/2018
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 1,000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />X
<br />$
<br />Hired /Nonown
<br />A
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />Y
<br />Y
<br />UL90714909
<br />5/22/2017
<br />5/22/2018
<br />EACH OCCURRENCE
<br />$ 3,000,000
<br />AGGREGATE
<br />$ 3,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED X RETENTION $
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />Y
<br />WCP100138707
<br />5/22/2017
<br />5/22/2018
<br />1 OTH-
<br />STATUTE I ER
<br />ANYPROPRIETOR /PARTNER /EXECUTIVE
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />OFFICER /MEMBER EXCLUDED?
<br />N/A
<br />(Mandatory in NH)
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />A
<br />Leased /Rented Equipment
<br />CL90640065
<br />5/22/2017
<br />5/22/2018
<br />$500 Deductible
<br />85,000
<br />Installation Floater
<br />$1,000 Deductible
<br />105,000
<br />Owned Equipment
<br />$500 Deductible
<br />$73,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Certificate Holder and any other parties as required is Additional Insured with regards to General Liability, Automobile and Umbrella as required by written
<br />contract. Additional Insured's are afforded a Wavier of Subrogation with regards to General Liability, Automobile, Umbrella and Workers Compensation as
<br />required by written contract. Umbrella is following form to the General Liability, Automobile Liability and Employers Liability policies.
<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 />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Orange County
<br />PO Box 8181
<br />AUTHORIZED REPRESENTATIVE
<br />Hillsborough NC 27278
<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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