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DocuSign Envelope ID: 7295DAE7 -1 D24- 460B- 843D- 4875267133AA <br />A`� " CERTIFICATE OF LIABILITY INSURANCE <br />GATE (MMIDD1YYYYI <br />71912018 <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 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(sj, <br />'PRODUCER <br />Jones Insurance Agency Inc. <br />8217 Benson Road <br />Garner NC 27529 <br />CONTACT <br />NAME: Heidi Morse <br />PHONE y FAIL <br />• 919 - 772 -0233 ruc No l;919--79 -4025 <br />nd REESS- heldim@iones-(nsurance.com <br />INSURERS AFFORDING COVERAGE <br />NAIC N <br />Y <br />INSURER A: Accident Fund Ins Co of Amer <br />10166 <br />_ <br />INSURED NWPOOLE -01 <br />L.etco Inc dba N W Poole Well & Pump Co <br />P.O. Box 1958 <br />INSURER B: Selective Insurance Company of the Southeast <br />39926 <br />INSURER £ <br />CLAIMS-MADE I OCCUR <br />INSURER 0 <br />Wendell NC 27591 <br />INSURER E: <br />INSURER F: <br />5300,000 <br />COVERAGES CERTIFICATE NUMBER: 866884075 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 />EXCLUSIDNS 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 />SUBR <br />POLICY NUMBER <br />POLICY Err <br />MMIDO <br />POLICY EXP <br />MMMDIYYYY <br />LIMITS <br />B <br />X <br />COMMERCIAL GENERAL LIABILITY <br />Y <br />52367053 <br />711=18 <br />71112018 <br />EACH OCCURRENCE <br />$1,000,000 <br />CLAIMS-MADE I OCCUR <br />DAMAGE 70 RENTED <br />PRE SES Ea dCCUtre ce <br />5300,000 <br />MED EXP (Any one person) <br />$10.000 <br />PERSONAL & ADV INJURY <br />S 1,000,o0D <br />GENT AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$ 3,00D,000 <br />POLICY PRO F-] LOC <br />JECT <br />PRODUCTS - COMP /OP AGG <br />S 3.000,000 <br />S <br />OTHER: <br />B <br />AUTOMOBILE <br />LIABILITY <br />Y <br />S23G7053 <br />71112018 <br />711/2019 <br />COMBINED SINGLE. LIMIT <br />Ea ac <br />$ 1,000,00D <br />BODILY INJURY (Per person) <br />$ <br />X <br />ANY AUTO <br />ALLOWPIED SCHEDULE{] <br />AUTOS AUTOS <br />BODILY INJURY (par accident) <br />$ <br />PROPERTY DAMAGE <br />_ accident <br />$ <br />X <br />NON-OWNED <br />HIRED AUTOS AUTOS <br />B <br />X <br />UMBRELLA LIAR X OCCUR <br />52367053 <br />71112018 <br />71112019 <br />EACH OCCURRENCE <br />52,000,000 <br />AGGREGATE <br />S <br />EXCESS LIAB CLAIMS -MADE <br />5 <br />OED I I RETENTION $ <br />A <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />VVGV6130199 <br />7/112018 <br />71112019 <br />x I STATUTE OERw- <br />ANY PROPRIETORIPARTNERIEXECUTIVE F--1 <br />E-L. EACH ACCIDENT <br />S 590,000 <br />OFFICERIMEMBER EXCLUDED? <br />NIA <br />E.L. DISEASE - EA EMPLOYEd <br />s500,000 <br />(Mandatory In NH) <br />If yes, describe under <br />i7ESCMPTION OF OPERATIONS below <br />E.L. DISEASE- POLICY LIMIT <br />I 5500,000 <br />B <br />Inslallatlon Floater <br />82387053 <br />71112018 <br />711/2019 <br />Installation Limit 150,DOO <br />Leased/RenW Equipment <br />Leased/Rented 25.OD0 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) <br />The General Liability policy includes an additional insured endorsement that {provides additional insured status for on ping operations and products and <br />completed operations and a waiver of subrogation endorsement that provides waiver of subrogation status to the certipcate holder and other entities when there <br />is a written "Insured contract" between named insured and certificate holder that requires such status, - The General Liablilty policy contains an endorsement <br />providing primary and non - contributory status when a written "insured contract' requires such status. <br />• The Auto Liability policy includes an additional Insured endorsement that provides additional insured status and a waiver of subrogation endorsement that <br />provides waiver of subrogation status to the certificate holder and other entitles when there is a written "insured contract" between named insured and certificate <br />holder that requires such status. <br />• The Workers Compensation policy Includes a waiver of subrogation endorsement that provides waiver of subrogation status to the certificate holder and other <br />See Attached,.. <br />CERTIFICATE HOLDER CANCELLATION <br />Orange County Parks & Recreation <br />ISO Box 8181 <br />Hillsborough NC 27278 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUT ORIZED REPRESENTATIVE <br />r M <br />@ 1988 -2014 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2014101 ) The ACORD name and logo are registered marks of ACORD <br />