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ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? <br />INSRADDLSUBRLTRINSDWVD <br />PRODUCER CONTACTNAME: <br />FAXPHONE(A/C, No):(A/C, No, Ext): <br />E-MAILADDRESS: <br />INSURER A : <br />INSURED INSURER B : <br />INSURER C : <br />INSURER D : <br />INSURER E : <br />INSURER F : <br />POLICY NUMBER POLICY EFFPOLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) <br />AUTOMOBILE LIABILITY <br />UMBRELLA LIAB <br />EXCESS LIAB <br />WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />AUTHORIZED REPRESENTATIVE <br />EACH OCCURRENCE$ <br />DAMAGE TO RENTEDCLAIMS-MADEOCCUR $PREMISES (Ea occurrence) <br />MED EXP (Any one person)$ <br />PERSONAL & ADV INJURY$ <br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ <br />PRO-POLICYLOC PRODUCTS - COMP/OP AGGJECT <br />OTHER:$ <br />COMBINED SINGLE LIMIT $(Ea accident) <br />ANY AUTO BODILY INJURY (Per person)$ <br />OWNEDSCHEDULED BODILY INJURY (Per accident)$AUTOS ONLYAUTOS <br />HIREDNON-OWNED PROPERTY DAMAGE $AUTOS ONLYAUTOS ONLY (Per accident) <br />$ <br />OCCUR EACH OCCURRENCE <br />CLAIMS-MADE AGGREGATE$ <br />DEDRETENTION$ <br />PEROTH-STATUTEER <br />E.L. EACH ACCIDENT <br />E.L. DISEASE - EA EMPLOYEE$ <br />If yes, describe under <br />E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below <br />INSURER(S) AFFORDING COVERAGENAIC # <br />COMMERCIAL GENERAL LIABILITY <br />Y / N <br />N / A <br />(Mandatory in NH) <br />SHOULDANYOFTHEABOVEDESCRIBEDPOLICIESBECANCELLEDBEFORE <br />THEEXPIRATIONDATETHEREOF,NOTICEWILLBEDELIVEREDIN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />THISISTOCERTIFYTHATTHEPOLICIESOFINSURANCELISTEDBELOWHAVEBEENISSUEDTOTHEINSUREDNAMEDABOVEFORTHEPOLICYPERIOD <br />INDICATED.NOTWITHSTANDINGANYREQUIREMENT,TERMORCONDITIONOFANYCONTRACTOROTHERDOCUMENTWITHRESPECTTOWHICHTHIS <br />CERTIFICATEMAYBEISSUEDORMAYPERTAIN,THEINSURANCEAFFORDEDBYTHEPOLICIESDESCRIBEDHEREINISSUBJECTTOALLTHETERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />THISCERTIFICATEISISSUEDASAMATTEROFINFORMATIONONLYANDCONFERSNORIGHTSUPONTHECERTIFICATEHOLDER.THIS <br />CERTIFICATEDOESNOTAFFIRMATIVELYORNEGATIVELYAMEND,EXTENDORALTERTHECOVERAGEAFFORDEDBYTHEPOLICIES <br />BELOW.THISCERTIFICATEOFINSURANCEDOESNOTCONSTITUTEACONTRACTBETWEENTHEISSUINGINSURER(S),AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT:IfthecertificateholderisanADDITIONALINSURED,thepolicy(ies)musthaveADDITIONALINSUREDprovisionsorbeendorsed. <br />IfSUBROGATIONISWAIVED,subjecttothetermsandconditionsofthepolicy,certainpoliciesmayrequireanendorsement.Astatementon <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />COVERAGESCERTIFICATE NUMBER:REVISION NUMBER: <br />CERTIFICATE HOLDERCANCELLATION <br />© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) <br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) <br />$ <br />$ <br />$ <br />$ <br />$ <br />The ACORD name and logo are registered marks of ACORD <br />Adam Andrews <br />TERRA-2OP ID: SF <br />10/02/2017 <br />Shelley L. Fera <br />Southeastern Agency Group,Inc. <br />1501 Highwoods Blvd., St # 402Greensboro, NC 27410Adam Andrews <br />336-218-7470336-218-7487 <br />sfera@sagnc.com <br />EMC Insurance Companies <br />Travelers Property Casualty CoTerraquest Environmental <br />Consultants, PC <br />100 E Ruffin St <br />Mebane, NC 27302 <br />Admiral Insurance Co <br />C X 10,000,000 <br />X FEI-ECC-24055-0009/11/201709/11/2018 100,000 <br />25,000 <br />1,000,000 <br />2,000,000 <br />2,000,000 <br />1,000,000A <br />X 5E6518409/11/201709/11/2018 <br />X 1,000,000C <br />FEI-EXS-24056-0009/11/201709/11/2018 <br />XB <br />6JUB-8H31614309/11/201709/11/2018 1,000,000 <br />1,000,000 <br />1,000,000 <br />C FEI-ECC-24055-0009/11/201709/11/2018 Aggregate1,000,000 <br />C Professional LiabFEI-ECC-24055-0009/11/201709/11/2018 Aggregate1,000,000 <br />ROGERSI <br />Rogers Insurance Agency <br />512 West Williams Street <br />Apex, NC 27502 <br />336-218-7470 <br />21415 <br />Pollution Liab <br />DocuSign Envelope ID: 0775346B-8C75-486B-A5A3-CACF4261E2AA