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DocuSign Envelope ID: 23B19021- F3AC- 4D83- B621- FD21A11682EC <br />CORRECTED NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY, INC. <br />CERTIFICATE OF LIABILITY INSURANCE <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(les) must be endorsed. It SUBROGATION IS WAIVED, subject <br />to the terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to <br />the certificate holder in lieu of such endorsement(s). <br />INSURED DOUG MALINOWSKI JR <br />NAMEAND DBA WELLSMONT LANDSCAPING <br />ADDRESS 1740 JOHNSON ROAD <br />BURLINGTON NC 27217 <br />CERTIFICATE ORANGE COUNTY PLANNING AND <br />HOLDER INSPECTIONS DEPT <br />CSANDT6a ORANGECOUNTYNC.GOV <br />131 W MARGARET LANE <br />PO BOX 8181 <br />HILLSBOROUGH NC 27278 <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 REOUIREPAENT, TEPM C11. 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 />X TYPE OFI SURANCE ADDL'SUBR MJCYNUIMBER POLICYE'FF I PC!R EXP LIMITS <br />X COMMERCIAL GENERAL LIABILITY X GL 0483161 2/23/2018 2/2312019 <br />- OCCURRENCE <br />GEN'L AGGREGATE APPLIES PER POLICY <br />BUSINESSOW NERS <br />IUTDf+ OBILE LIABILITY <br />SCHEDULEDAUTOS BAP 2177023 2/24/2018 8/24/2018 <br />HIRED AUTOS <br />NON -OWNED AUTOS <br />GARAGE I.IASII..ITY <br />(Oftr) <br />GENERAL AGGREGATE <br />$2'U1 <br />PRODUCTS - COMPIOPS <br />AGGREGATE <br />$0 <br />PERSONAL & ADV INJURY <br />$110 <br />EACH OCCURRENCE <br />$1,0( <br />DAMAGE TO RENTED <br />$1 <br />MED EXP (Any one parson) <br />$5.0( <br />EACH OCCURRENCE Is <br />AGGREGATE I $ <br />COMBINED SINGLE LIMIT <br />50�10(�0 <br />(Each awdem) <br />BODILY INJURY (Per person) $ <br />BODILY INJURY (Per s=ided)) $ <br />PROPERTY DAMAGE $ <br />I EACH OCCURRENCE $ <br />EXCESS LIABILITY- - <br />OCCURRENCE AGGREGATE $ <br />WC STATUTORY LIMITS <br />X WORKERS COMPENSATION NIA, WC 0253741 8/24/2017 8124/2018 ' E.L EACH ACCIDENT $100,000 <br />AND EMPLOYERS "LIABILITY _ <br />POLICY APPLIES TO THE WORKERS L DISEASE - EA EMPLOYEE 1 $140,000 <br />i <br />COMPENSATION LAW IN THE STATE or NC = L DISEASE - POLICY umrT $Ej00,000 <br />OTHER: <br />DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES: <br />--I ■laLLr --t{ I I%JIY <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE <br />DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />L.M. Squires C ,fy) <br />DATE JUNE 12, 2018 '' J <br />COI 0910 <br />068 55381smf <br />