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DocuSign Envelope ID:93C4AB5D-9B56-4AE2-8617-1374826692F7 SEALTD2
<br /> 0 DATE(MMMDIYYYY)
<br /> '4CM a CERTIFICATE OF LIABILITY INSURANCE
<br /> 10/18/2018
<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: It 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 floes not confer rights to the certificate holder in lieu of such endorsement(s).
<br /> PRODUCER CONTACT
<br /> NAME; Ginny Peters
<br /> Commercial Lines-(614)228-5565 PHOON a �, 614-407-7535 FAX,No]; 610-537-2008
<br /> USI Insurance Services National,Inc. E-MAIL inn eters usi.com
<br /> ADDRESS: 9 yP @
<br /> 5455 Rings Road,Suite 250 INSURER(S)AFFORDING COVERAGE NAIL#
<br /> Dublin,OH 43017 INSURERA; Federal Insurance Company 20281
<br /> INSURED INSURER s: Great Northern Insurance Company 20303
<br /> SEA, Ltd. INSURER C. Vigilant Insurance Company 20397
<br /> 7001 Buffalo Parkway INSURER D: Executive Risk Indemnity 35181
<br /> INSURER E:
<br /> Columbus OH 43229 INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 13557387 REVISION NUMBER: See below
<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 /> INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS
<br /> I,TR I POLICY NUMBER MMIDDIYYYY MM76DlYYYY
<br /> )(
<br /> A COMA6ERCIAL GENERAL LIABILITY X 35783620 10/1/2018 10/1/2019 EACH OCCURRENCE 5 1,000,000
<br /> �OCCUR PREMISES O N
<br /> CLAIMS-MADE
<br /> PREMISES Ea Occurrence $ 1,000,000
<br /> MED EXP(Any one person) S 10,000
<br /> PERSONAL$ADV INJURY 5 1,000,000
<br /> GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> X POLICY Fx_1 ECT F—]LOC PRODUCTS-COMPIOPAGG $ 1,000,000
<br /> OTHER: Ohio Stop Gap S 1,000,000
<br /> B AUTOMOBILE LIABILITY 73514769 10/01/2018 10/01/2019 EOa MBBIINEED[SINGL -LIMIT is 1,000,000
<br /> jXxx ANY A UTO BODILY INJURY(Per person) $
<br /> OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS ONLY AUTOS
<br /> HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY . AUTOS ONLY Per accident
<br /> X Comp/Coll De 1,000 $
<br /> UMBRELLALiAB OCCUR EACH OCCURRENCE $
<br /> ExCE55 LIAB HCLAIMS-MADE AGGREGATE $
<br /> OED i RETENTION$ $
<br /> WORKERS COMPENSATION 10/01/2018 10/01/2019 X PER OTH-
<br /> C AND EMPLOYERS'LIABILITY Y I N 71655162 STATUTE ER
<br /> ANYPROPRIETORIPARTNERIEXECUTIVE E.L EACH ACCIDENT $ 1,000,000
<br /> OFFICERIMEMBEREXCLUDEO, L NIA
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000
<br /> H yes describe under 1,000,000
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5
<br /> D Professional Liability 81729143 10/01/2018 10/01/2019 $7,000,000$50,000 Deductible
<br /> DESCRIPTION OF OPERATIONS F LOCATIONS i VEHICLES(ACORD 141,Additional Remarks Schedule,may be attached it more space is required)
<br /> Certificate holder is named as additional insured as it relates to general liability in accordance with the terms and conditions of the policy.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Orange County,North Carolina SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> 200 S.Cameron Street ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Hillsborough,NC 27278
<br /> AUTHORIZED REPRESENTATIVE,r��+J+,
<br /> The ACORD name and logo are registered marks of ACORD 1988-201lf5 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016103)
<br />
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