Orange County NC Website
Browse       Search
DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973DO39 <br />OP 1D: KR <br />DATE IMMIDDIYYYYi <br />CERTIFICATE OF LIABILITY INSURANCE 06/2612018 <br />THIS CERTIFICATE I5 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS <br />ER THE COVERAGE AFFORDED BY THE POLICIES <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALT <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(s). HTA T <br />PRODUCER HA E: Kim Rhodes <br />CITIZENS INSURANCE AGENCY PHONE e� 262-492 -4061 iuc NO: <br />P 0 BOX 109 a MA L <br />HENDERSON, NC 27536 ADDRESS: kirn�ncagent.cam <br />W PRODUCER_, CLUBN -2 nus9 Account/Joel T. Cheatham ,, <br />INSURED Club Nava Community, lr <br />P.O. Box 1345 <br />Carrboro, NC 278104346 <br />CO <br />3VERAGES %,CM I Imam I c nuniw� .-- <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD T TO WHICH THIS <br />INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM oft CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />e—%i , ,a,n,,ec eun rrlummnN.r, nF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- <br />IiT� <br />TYPHOFINSURANCE <br />FACH OC%fJJUR <br />S <br />RFNERAL WBILrrY <br />07101/2018 <br />0710112019 <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />P'' <br />X I CLAIMS -MADE 0 OCCUR <br />S <br />x Retro 5113106 <br />PERSONRY <br />S <br />GEN'L AGGREGATE LIMITAPPLIES PER <br />GENE- AE <br />S <br />X POLICY Q PRO LOC <br />AUTOMOBILE LIABILITY <br />PRODUCAGG <br />S 3 <br />B <br />X ANY AUTO <br />F <br />S <br />ALL OWNED AUTOS <br />COMBINED SINGLE LIMIT <br />5CHEOULEO AUTOS <br />HP K1642347 <br />0710112016 <br />0710112019 <br />X H €RED AUTOS <br />S <br />F <br />B <br />X NGN- OWNEDAUTOS <br />BODILYINJURY(Peraxidonll S <br />1 <br />UMBRELLA LU+B OCCUR <br />PROPERTY DAMAGE <br />S <br />HPK1842347 <br />EXCESS LtAe CLAIMS M4OE <br />0710`112018 <br />(PERACCIDElrr) <br />oVOUCT1BL6 <br />HPK1842347 <br />071o112o1B <br />07101/2019 <br />MedPay <br />RETENTION <br />WORKERS COMPENSATION <br />s _ <br />AND EMPLOYERS' UABILM YIN <br />ANY pROPRMTOR1PARTHER/BXECUT\!£ r } <br />N 1 A <br />OFFICERtMEMBER EXCLUDED? <br />{Mandatary le NHI <br />Iles , descnAe under <br />DCRIPTION OF OPERATIONS below <br />A <br />Professional Liab. <br />Claims Made RETRO 5113106 <br />DESCRIPTION OF OPERATIONS! LeCA110N8 r VEHIOLBS (AtUch ACORD 101, AddWanal R11rd4*6 Bahrdult, It man coca +la nqulnd) <br />I E L DISEASE - EA EMPLOYEE) S <br />3,00 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN <br />Orange County ACCORDANCE WITH THE POLICY PROVISIONS. <br />200 S Cameron St <br />Hillsbarough, NC 27278 Au O R6PR98%y�ATIYE <br />Buse counU oat T. Cheatham <br />E <br />d 1988.2005 ACORD COftpeMTION. All rights reserved. <br />ACORD 26 (2009108), The ACORD name and logo are registered marks of ACORD <br />FACH OC%fJJUR <br />S <br />4PK1842347 <br />07101/2018 <br />0710112019 <br />PREMISEee <br />S <br />MED E XP on) <br />S <br />PERSONRY <br />S <br />GENE- AE <br />S <br />PRODUCAGG <br />S 3 <br />S <br />COMBINED SINGLE LIMIT <br />S <br />HP K1642347 <br />0710112016 <br />0710112019 <br />IEa eccidenl ) <br />BODILY INJURY (Per parson) <br />S <br />BODILYINJURY(Peraxidonll S <br />PROPERTY DAMAGE <br />S <br />HPK1842347 <br />0710112018 <br />0710`112018 <br />(PERACCIDElrr) <br />HPK1842347 <br />071o112o1B <br />07101/2019 <br />MedPay <br />S <br />UM1U1141 <br />s _ <br />Claims Made RETRO 5113106 <br />DESCRIPTION OF OPERATIONS! LeCA110N8 r VEHIOLBS (AtUch ACORD 101, AddWanal R11rd4*6 Bahrdult, It man coca +la nqulnd) <br />I E L DISEASE - EA EMPLOYEE) S <br />3,00 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN <br />Orange County ACCORDANCE WITH THE POLICY PROVISIONS. <br />200 S Cameron St <br />Hillsbarough, NC 27278 Au O R6PR98%y�ATIYE <br />Buse counU oat T. Cheatham <br />E <br />d 1988.2005 ACORD COftpeMTION. All rights reserved. <br />ACORD 26 (2009108), The ACORD name and logo are registered marks of ACORD <br />