Orange County NC Website
DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE <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(s). <br />CONTACTPRODUCERNAME: <br />FAXPHONE <br />(A/C, No):(A/C, No, Ext): <br />E-MAIL <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURER A : <br />INSURED INSURER B : <br />INSURER C : <br />INSURER D : <br />INSURER E : <br />INSURER F : <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 />ADDL SUBRINSR POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITSPOLICY NUMBERLTR (MM/DD/YYYY)(MM/DD/YYYY)INSD WVD <br />COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br />DAMAGE TO RENTED <br />CLAIMS-MADE OCCUR $PREMISES (Ea occurrence) <br />MED EXP (Any one person)$ <br />PERSONAL & ADV INJURY $ <br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ <br />PRO-POLICY LOC PRODUCTS - COMP/OP AGG $JECT <br />$OTHER: <br />COMBINED SINGLE LIMITAUTOMOBILE LIABILITY $(Ea accident) <br />BODILY INJURY (Per person)$ANY AUTO <br />ALL OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS AUTOS <br />NON-OWNED PROPERTY DAMAGE $HIRED AUTOS (Per accident)AUTOS <br />$ <br />UMBRELLA LIAB EACH OCCURRENCE $OCCUR <br />EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br />$DED RETENTION $ <br />PER OTH-WORKERS COMPENSATION STATUTE ERAND EMPLOYERS' LIABILITY Y / N <br />ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $N / AOFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $ <br />If yes, describe under <br />E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS / LOCATIONS / 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 />The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01) <br />TOTAL-7 OP ID: LH <br />05/24/2018 <br />Laura Adams <br />Brown & Brown of SC <br />PO Box 16837 <br />Greenville, SC 29606 <br />864-234-8889 864-527-1147 <br />ladams@bbsouthcarolina.com <br />Selective Way Ins Co <br />Hartford Fire 19682Total Maintenance Solutions <br />P.O. Box 68 <br />Taylors, SC 29687 Selective Ins of SC 19259 <br />A X 1,000,000 <br />X S2233404 07/01/2017 07/01/2018 500,000 <br />15,000 <br />1,000,000 <br />2,000,000 <br />X 2,000,000 <br />1,000,000 <br />A X S2233404 07/01/2017 07/01/2018 <br />X X <br />XX 3,000,000 <br />A S2233404 07/01/2017 07/01/2018 3,000,000 <br />0X <br />C WC9030221 07/01/2017 07/01/2018 500,000 <br />500,000 <br />500,000 <br />A Property Section S2233404 07/01/2017 07/01/2018 <br />B Crime 22BDDEX3793 01/15/2017 01/15/2020 <br />Orange County <br />P.O. Box 8181 <br />Hillsborough, NC 27278 <br />DocuSign Envelope ID: DF45A6D9-A97B-4D15-B5E3-43F98C0505EB