Orange County NC Website
DocuSign Envelope ID: E5125061 -EBDC- 4026- B598- F44E12576444 <br />0 <br />AC"R" CERTIFICATE OF LIABILITY INSURANCE <br />[ fDATEJMMJDD/YYYY) <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 he 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 />PHONH Exl (888) 202 -3007 AX No); <br />Hiscox Inc <br />520 Madison Avenue <br />ADDRESS; contact @hiscox,com <br />INSURERS AFFORDING COVERAGE <br />NAIC If <br />32nd Floor <br />INSURER A. Hiscox Insurance Company Inc <br />10200 <br />New York, NY 10022 <br />INSURED <br />INSURER B <br />INSURER C ; <br />5 <br />Benjamin Beaton <br />INSURER D ; <br />PERSONAL & ADV INJURY <br />107 James Helen Ct. <br />INSURER E: <br />GENERAL AGGREGATE <br />$ <br />INSURER F <br />$ <br />Willow Spring NC 27592 <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 />AODL <br />D <br />SUER <br />D <br />POLICYNUMBER <br />POLICY EFP <br />MhVDD <br />POLICY EXP <br />MMIDD <br />LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />IM <br />CLAWS-MADE 1-1 OCCUR <br />EACHDGGURRENCE <br />$ <br />PRENI SES fra£ <br />raurence )— <br />$ �� <br />h1ED EXP (Any one person) <br />5 <br />PERSONAL & ADV INJURY <br />$ <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />POLICY ❑ PRO- ❑ LOC <br />JECT <br />OTHER: <br />GENERAL AGGREGATE <br />$ <br />PRODUCTS - CO%IP1OP AGG <br />$ <br />S <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />CO a ",IBINEO SINGLE LIMIT <br />en <br />E accid t <br />$ <br />BODILY INJURY (Per person) <br />$ <br />BODILY INJURY (Per acMenl) <br />PROPERTY DAI AGE <br />Per accdent <br />$ <br />UMBRELLALIAS <br />EXCESS LIAB <br />OCCUR <br />CLAIMS -MADE <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />DED RETENTION S <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANYPROPRIETORIPARTNERIEXECLrTfVE <br />OFFICERAIEMBERFXCLUDED7 <br />(Mandatory In NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS beVv <br />NIA <br />PER OTH- <br />STATUTE ER <br />E.L. EACH ACCIDENT <br />$ <br />E.L.DISEASE- EAFNIPLOYF <br />$ <br />E.L. DISEASE - POLICY LIMIT <br />$ <br />A <br />Proressional Liability <br />UDC - 1774785 -EO -18 <br />07/01/2018 <br />07/01/2019 <br />Each Claim: $ 250,000 <br />Aggregate: $ 250,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) <br />CERTIFICATE HOLDER CANCELLATION <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 />@ 1988 -2014 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />