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DocuSign Envelope ID:52FB3400-CB52-4D46-9231-157F153B491B <br /> DATE{MMIDDNWY) <br /> A�cap CERTIFICATE OF LIABILITY INSURANCE <br /> 0912712017 <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 have ADDITIONAL INSURED provisions or be endorsed. <br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT Courtney Hartman <br /> NAME: _ <br /> StateF r MARY WILSON STATE FARM PHCNNO Exi: 919-872-1225 Pa c No): 919-676-2327 <br /> M 9660 FALLS OF NEUSE RD SUITE 165 ADO!Ess: Courtney @MARYWILSONSMYAGENT.COM <br /> RALEIGH NC 27615 <br /> INSURER{S)AFFORDING COVERAGE NAIL# <br /> INSURERA: State Farm Mutual Automobile Insurance Company 25178 <br /> INSURED INSURER B: <br /> ROCCHETTI,RICKY&LINDA J INSURER C: <br /> 16204 HALLBERG LN INSURER D: <br /> RALEIGH NC 27614-7716 INSURERE: <br /> INSURER F:_ <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 13EFN 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 13E- 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 /> INSR ADDL SUBR - POLICY EFF POLICY EXP LIMITS <br /> LTR TYPE OF INSURANCE POLICY NUMBER MMID MMIDDIYYYY <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE <br /> i DAMAGE TO RENTED <br /> CLAIMS-MADE El OCCUR PREMISES Ea occurrence $ <br /> MEP EXP(Any one person) $ <br /> PERSONAL&ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ <br /> JECT <br /> POLICY PRO LOG PRODUCTS-COMPIOP AGG $ <br /> OTHER' $ <br /> COMB <br /> AUTOMOBILE LIABILITY <br /> COMBINED SINGLE LIMIT $ <br /> Ea accident <br /> ANY AUTO 377 8201-D21-33D 09127/2017 04/2112018 BODILY INJURY(Per person) $ 100,000 <br /> A OWNED SCHEDULED BODILY INJURY(PeTamiriont) $ 300,000 <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OVNVED E PROPERTY DAMAGE <br /> AUTOS ONLY AUTOS ONLY Per accidenR <br /> $ <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE <br /> EXCESS LIAB CLAIMS-MADE I AGGREGATE $ <br /> DED I I RETENTION$ $ <br /> WORKERS COMPENSATION PER OTH- <br /> UTE <br /> AND EMPLOYERS'LIABILITY <br /> ANY PROPRIETORIPARTNERIEXECUTIVE YIN STAT ER <br /> E.L.EACH ACCIDENT $ <br /> OFFICERIMEMBER EXCLUDED? N NIA <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS beiow E.L.DISEASE-POLICY LIMIT $ <br /> f <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES tACORD 101,Additional Remarks Schedule,may he 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 RE It �NT�TIVE� j � l <br /> O 1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br /> 100148Ps 732848.12 03-16-2616 <br />