|
DocuSign Envelope ID: 2042AF9E- 4D4F- 4C48- 9CFC- 66AF31AB811D
<br />STREE -1 OP ID: JO
<br />4C 1:> CERTIFICATE OF LIABILITY INSURANCE
<br />�--��
<br />DATE 08 /24 /201 YY)
<br />08/24/2016
<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 be endorsed. If SUBROGATION IS WAIVED, 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 endorsement(s).
<br />PRODUCER
<br />Harold W. Wells & Son, Inc.
<br />One North Third Street
<br />NAME: Doug Johnston, CIC, CBIA
<br />PHONE FAX
<br />A/C No Ext :910- 251 -5432 A/c, No): 910- 254 -9404
<br />ADDRESS: insurance @wellsins.com
<br />Wilmington, NC 28401 -4528
<br />Harold W. Wells & Son, Inc.
<br />COMMERCIAL GENERAL LIABILITY
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Philadelphia Indemnity Ins. Co
<br />18058
<br />$ 1,000,000
<br />INSURED S Solutions, Inc. dba Street
<br />INSURER B: Accident Fund Ins Co ofAmerica
<br />10166
<br />Safe
<br />PO Box 1541
<br />INSURER C,
<br />09/28/2015
<br />09/28/2016
<br />Wilmington, NC 28402 -1541
<br />INSURER D:
<br />INSURER E:
<br />$ 5,000
<br />INSURER F;
<br />COVERAGES CERTIFICATE NUMBER: 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 />POLICY NUMBER
<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 />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE � OCCUR
<br />X
<br />PHPK1399287
<br />09/28/2015
<br />09/28/2016
<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 />PRO -
<br />POLICY �
<br />POLICY [::] LOC
<br />X
<br />PRODUCTS - COMP /OP AGG
<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 />A
<br />ANY AUTO
<br />PHPK1399287
<br />09/28/2015
<br />09/28/2016
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />NON -OWNED
<br />HIRED AUTOS AUTOS
<br />UMBRELLA LIAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED RETENTION $
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR /PARTNER /EXECUTIVE Y
<br />OFFICER /MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />N/A
<br />WCV6117551*
<br />09/28/2015
<br />09/28/2016
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<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 />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />DOUG DARRELL, KAYNE DARRELL, WILLIAM HOEST, AND NICHOLAS MYKULAK HAVE
<br />ELECTED TO BE EXCLUDED FROM THE WORKERS COMP POLICY
<br />IL" a ;11112LOY-11 fl=1111 Lai 4na: hG10Lha4WtU Lai 0
<br />ORANG -1
<br />Orange County Schools
<br />200 E King St
<br />Hillsborough, NC 27278
<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 />AUTHORIZED REPRESENTATIVE
<br />Harold W. Wells & Son, Inc.
<br />©1988 -2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />
|