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DocuSign Envelope ID: 6CCCCAFC -C372- 4560 - ACEB- 744BF96E8287 <br />A� <br />1 0 CERTIFICATE OF LIABILITY INSURANCE <br />DATE <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />5/14/201gvvY) <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: <br />A/C. No Ext : (919)256-6860 FAX No): (877)515-4166 <br />J. LOOS & ASSOCIATES, INC. <br />ADM DRESS: jim.loos@jloosins.com <br />7500 Mine Shaft Rd <br />INSURERS AFFORDING COVERAGE <br />NAIC # <br />Raleigh, NC 27615 <br />INSURER A: United Specialty Insurance Co <br />34452 <br />INSURED <br />INSURER B: State National Insurance Co. <br />31895 <br />Carolina Lead Abatement, Inc. <br />INSURER C: Homeland Ins. Co. of New York <br />34452 <br />INSURER D: <br />MED EXP (Any one person) <br />$ 5,000 <br />INSURER E: <br />Contractor Pollution <br />7246 Taylor Store Rd <br />INSURER F: <br />Nashville, NC 27856 <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 />I NSR <br />LTR <br />TYPE OF INSURANCE <br />INSD <br />WVD <br />POLICY NUMBER <br />MM DI D YYYY <br />MM /DD YYYY <br />LIMITS <br />X <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,000 <br />CLAIMS -MADE � OCCUR <br />PREM S" (,..NcurrD.r ce ) <br />$ 100,000 <br />X <br />MED EXP (Any one person) <br />$ 5,000 <br />Contractor Pollution <br />PERSONAL & ADV INJURY <br />$ 1,000,000 <br />A <br />USA4194035 <br />11/1412017 <br />11/14/2018 <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />POLICY � PRO JECT 1:1 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 />$ <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 />UMBRELLA LIAB <br />X <br />OCCUR <br />EACH OCCURRENCE <br />$ 10,000,000 <br />X <br />AGGREGATE <br />$ 10,000,000 <br />C <br />EXCESS LIAB <br />CLAIMS -MADE <br />793- 00 -71 -94 -0000 <br />11/1412017 <br />11/14/2018 <br />DED RETENTION $ <br />$ <br />B <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOR /PARTNER /EXECUTIVE YIN N <br />OFFICER /MEMBER EXCLUDED? YI <br />(Mandatory in NH) <br />NIA <br />NFA 0868070 <br />11/14/2017 <br />11/14/2018 <br />X SEATUTE OERH <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 />Orange County is an additional insured for general liability as required by written contract. Waiver of subrogation applies to Work Comp in favor of <br />Orange County as required by written contract. <br />CERTIFICATE HOLDER CANCELLATION <br />Orange County Planning and Inspections <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Department <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Engineering /Stormwater Division <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />131 W. Margaret Lane (P.O. Box 8181) <br />AUTHORIZED REPRESENTATIVE <br />Hillsborough, NC 27278.. <br />© 1988 -2015 AbeRD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />