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DocuSign Envelope ID: 88D4232D -A1 F7- 456E- 86CE- DA0982477F31
<br />CUSTCON -01
<br />DMASON
<br />AC ©�� CERTIFICATE OF LIABILITY INSURANCE
<br />��
<br />DATE(MMIDDIYYYY)
<br />06/29/2018
<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:
<br />PHONE FAX
<br />(A/C, No, Ext): (919) 968 -4472 (A/C, No): (919) 942 -4221
<br />Summers Thompson Lowry, Inc.
<br />100 Europa Drive
<br />Suite 571
<br />ADDRESS: info @STLinsure.com
<br />Chapel Hill, NC 27517 -2393
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: The Travelers Property Casualty Insurance Company of America
<br />25674
<br />INSURED
<br />INSURER 13: Standard Fire Insurance Company
<br />19070
<br />INSURER C:
<br />$ 10,000
<br />Custom Controls Unlimited Inc.
<br />INSURER D:
<br />PERSONAL & ADV INJURY
<br />2600 Garner Station Blvd
<br />Raleigh, NC 27603
<br />INSURER E
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY PRO-
<br />JECT 1:1 LOC
<br />OTHER:
<br />INSURER F:
<br />$ 2,000,000
<br />PRODUCTS - COMP /OP AGG
<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 />CLAIMS -MADE X OCCUR
<br />X
<br />ZLP81 M77236
<br />04/03/2018
<br />04/03/2019
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />300,000
<br />$
<br />MED EXP (Any one person)
<br />$ 10,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY PRO-
<br />JECT 1:1 LOC
<br />OTHER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />PRODUCTS - COMP /OP AGG
<br />$ 2,000,000
<br />$
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />BA3J500451
<br />04/03/2018
<br />04103/2019
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,000,000
<br />$
<br />X
<br />BODILY INJURY Per person)
<br />$
<br />BODILY INJURY Per accident
<br />$
<br />PROPERTY DAMAGE
<br />Per acciden t)
<br />$
<br />A
<br />X
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />X
<br />ZUP41 M75239
<br />04/03/2018
<br />04/03/2019
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />AGGREGATE
<br />$
<br />DED X RETENTION $ 10,000
<br />Aggregate
<br />$ 5,000,000
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />Y
<br />ANY PROPRIETOR /PARTNER/EXECUTIVE ❑
<br />OFFICER /MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />N / A
<br />X
<br />UB3J517642
<br />04/03/2018
<br />04/03/2019
<br />PER OTH-
<br />STAT LITE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />E.L. DISEASE - POLICY LIMIT
<br />1,000,000
<br />$
<br />A
<br />Prof Errors 8r Omissi
<br />ZPL31M77167
<br />04/04/2018
<br />04/04/2019
<br />Per Claim
<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 Planning and Inspections Department is listed as Additional Insured with respect to General Liability and Umbrella per written contract.
<br />CERTIFICATE HOLDER CANCELLATION
<br />ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />Orange Count Planning and Inspections Department
<br />9 Y 9 p p
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />PO Box 8181
<br />Hillsborough, INC 27278
<br />AUTHORIZED REPRESENTATIVE
<br />l.I F� S , 5
<br />ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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