Orange County NC Website
DocuSign Envelope ID: 3AD36C66- 5658 - 4281- 93DF- B77A9B2D44C6 <br />DATE tMMfDDIYYYY} <br />AtCCORDO CERTIFICATE OF LIABILITY INSURANCE <br />_ _ _ 07/09/2018 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIST <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(Sj, 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 CONTACT <br />NAME: <br />Hiscox Inc A%c °NEE 888 202 -3007 FAX <br />520 Madison Avenue ADDRIESS. contact@hiscox.com <br />32nd Floor INSURER(S) AFFORDING COVERAGE NAIC # <br />New York, NY 10022 INSURERA: Hiscox Insurance Company Inc 10200 <br />INSURED iucliaFa w <br />SHELTON HAYNES <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERNS OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />INSURERC: <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />555 E 78TH ST <br />ACCORDANCE WITH THE POLICY PROVISIONS.. <br />INSURERD: <br />COMMERCIAL GENERAL LIABILITY <br />613 <br />I NSU RER E - <br />NEW YORK NY 10075 <br />$ <br />INSURERF: <br />CLAIMS -MADE u OCCUR <br />rnVl- PIkr.FC rPRTI91 r ATl= MI IM RIP- R- <br />F2FVlglnM MIIMRFR- <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, TERNS 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 DESCRIBES] HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSI3 � - -- - -- ADDL SUHR POLICY E POLICY E %P LIMITS <br />LYR TYPEOFiNSURANCE POLICY NUMBER M FF MlDDfYYYY MMfDD <br />ACCORDANCE WITH THE POLICY PROVISIONS.. <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ <br />CLAIMS -MADE u OCCUR <br />GE TO RENTED <br />PRAEM SES f a occurranoa <br />$ <br />MED FXP (My cme person) <br />$ <br />$ <br />PERSONAL $ ADV INJURY <br />GENERAL AGGREGATE <br />$ <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />.._ <br />PRO - <br />POLICY E] JECT LOC <br />'. <br />- -- - <br />PRfldllCTS- COMP1flPAGG <br />- <br />$ <br />OTHER: <br />AUTOMOBILE LIABILITY <br />_ _ <br />COMBINED SINGLE LIMIT <br />Ea accidenl <br />$ <br />BODILY INJURY (Per person) <br />...(Per........ent) <br />_ <br />$ <br />ANYAUTO <br />$ <br />ALLOWNED SCHEDULED <br />AUTOS AUTOS <br />BO <br />BODILY INJURY [Per aakienl] <br />PROPERTY DAMAGE <br />Per accident)... ........... ..... <br />-_.._ <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />$ ...__ <br />$ <br />UMBRELLA LIAB DCCUR <br />EACHOCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAR CLAIM5•MAOE <br />—DE -0 <br />$ <br />RETENTIONS <br />WORKERS COM PEN SATiON <br />AND EMPLOYERS' LIABILITY YIN <br />ANYPROPRIETORfPARTNERfExECUTIVE <br />PER <br />TATUTE ER <br />__- <br />$ <br />E.L. EACH ACCIDENT <br />OFFICERJMEMBEREXCLUDED? ❑ <br />(Mandatory In NH) <br />N NIA <br />- <br />E.L. DISEASE - EA EMPLOYEE <br />_ <br />S - <br />L E.L• DISEASE - POLICY LIMIT <br />If yes. describe under <br />DESCRIPTION OF OPERATIONS below <br />$ <br />Professional Liability <br />Each Claim: $ 1,000,000 <br />A <br />UDC- 2303886 -EO -18 <br />07/0912018 <br />i <br />0714912019 <br />Aggregate: $1,000,000 <br />DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (ACORD tftl, Additional Remarks Schedule, maybe attached If more apace is required} <br />Anmvinll ATm Uf%k r%=M rAMrGI I ATInM <br />W IUUt1 -ZU14 AIL; UKU i;SAKVUKA I IUN. All rig nis reserved. <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 />W IUUt1 -ZU14 AIL; UKU i;SAKVUKA I IUN. All rig nis reserved. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />