Orange County NC Website
DocuSign Envelope ID: OE2F9DBB- D657- 45AD- B508- 556F4AE3530B <br />AC"R" CERTIFICATE OF LIABILITY INSURANCE <br />DATE (M hWDNYYY) <br />05/17/2018 <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(les) 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 />CONTACT <br />NAME: <br />PAHICNNo Ex • (888) 202 -3007 FAX No): <br />Hlscox Inc <br />520 Madison Avenue <br />E -MAIL <br />ADDRESS: Contact @hiscox.com <br />INSURERS AFFORDING COVERAGE <br />NAICJ <br />32nd Floor <br />INSURERA: Hiscox Insurance Company Inc <br />10200 <br />New York, NY 10022 <br />INSURED <br />INSURER B : <br />CLAPAS -MADE I OCCUR <br />INSURERC: <br />Silvia LissetteSaca <br />INSURER D : <br />103 N. Crabtree Knoll <br />INSURER E: <br />S <br />INSURER F: <br />5 <br />Chapel Hill NC 27514 <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 />WSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />SUBR <br />POLICY NUMBER <br />MM oDY EFF <br />MM1DD EXP <br />LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />S <br />CLAPAS -MADE I OCCUR <br />GE <br />PREMISESEa occur ante <br />S <br />ACED EXP (Anyone person) <br />5 <br />PERSONAL & AOV INJURY <br />S <br />G ENL AGGREGATE LIMIT APPLIES PER: <br />GEN ERAL AGGREGATE <br />S <br />POLICY PRO- LOC <br />PRODUCTS - COMP/OP AGO <br />S <br />$ <br />OTHER: <br />AUTOMOB[LELtABIL" <br />COI,9BINED SINGLE LIMIT <br />Ea accident <br />S <br />BODILY INJURY (Per person) <br />S <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />BODILY INJURY (Peraccdent) <br />S <br />' <br />PROPERTY DAMAGE <br />Par accident <br />S <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />$ <br />UMBRELLA LIAB <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAB <br />CLAIMS -MAOE <br />DED RETENTIONS <br />S <br />WORKERS COMPENSATION <br />AND EMPLOYERS'LIABILITY YIN <br />STATUTE ER <br />ANYPROPRIETOR/PARTNFR/EXECUTIV£ <br />E.L. EACH ACCIDENT <br />$ <br />OFFICERRdEMBEREXCLUDED7 ❑ <br />NIA <br />(Mandatory In NH) <br />E.L. DISEASE - EA EMPLOYEE <br />S <br />E.L- DISEASE - POLICY LIMIT <br />S <br />If yes, denim -be under <br />DESCRIPTION OF OPERATIONS be!ox <br />Professional Liability <br />Each Claim: $ 250,000 <br />A <br />UDC - 1763911 -EO -18 <br />07r0112018 <br />07/01/2019 <br />Aggregate: $ 250,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) <br />CFRTIFICATF HOI DFR CANCELLATION <br />©1988 -2014 ACORD CORPORATION. All rights reservea. <br />ACORD 25 (2014101) 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 />AUTHORIZED REPRESENTATIVE <br />F&ff 94 <br />©1988 -2014 ACORD CORPORATION. All rights reservea. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />