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ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? <br />INSRADDLSUBR <br />LTRINSDWVD <br />PRODUCER CONTACT <br />NAME: <br />FAXPHONE <br />(A/C, No):(A/C, No, Ext): <br />E-MAIL <br />ADDRESS: <br />INSURER A : <br />INSURED INSURER B : <br />INSURER C : <br />INSURER D : <br />INSURER E : <br />INSURER F : <br />POLICY NUMBER POLICY EFFPOLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) <br />AUTOMOBILE LIABILITY <br />UMBRELLA LIAB <br />EXCESS LIAB <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />AUTHORIZED REPRESENTATIVE <br />EACH OCCURRENCE$ <br />DAMAGE TO RENTEDCLAIMS-MADEOCCUR $PREMISES (Ea occurrence) <br />MED EXP (Any one person)$ <br />PERSONAL & ADV INJURY$ <br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ <br />PRO-POLICYLOC PRODUCTS - COMP/OP AGGJECT <br />OTHER:$ <br />COMBINED SINGLE LIMIT <br />$(Ea accident) <br />ANY AUTO BODILY INJURY (Per person)$ <br />OWNEDSCHEDULED <br />BODILY INJURY (Per accident)$AUTOS ONLYAUTOS <br />HIREDNON-OWNED PROPERTY DAMAGE <br />$AUTOS ONLYAUTOS ONLY (Per accident) <br />$ <br />OCCUR EACH OCCURRENCE <br />CLAIMS-MADE AGGREGATE$ <br />DEDRETENTION$ <br />PEROTH- <br />STATUTEER <br />E.L. EACH ACCIDENT <br />E.L. DISEASE - EA EMPLOYEE$ <br />If yes, describe under <br />E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below <br />INSURER(S) AFFORDING COVERAGENAIC # <br />COMMERCIAL GENERAL LIABILITY <br />Y / N <br />N / A <br />(Mandatory in NH) <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 />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 />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 />COVERAGESCERTIFICATE NUMBER:REVISION NUMBER: <br />CERTIFICATE HOLDERCANCELLATION <br />© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) <br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) <br />$ <br />$ <br />$ <br />$ <br />$ <br />The ACORD name and logo are registered marks of ACORD <br />10/15/2018 <br />License # 0E67768 <br />(678) 450-9180 <br />20281 <br />Quality Air Tool Repair, Inc. <br />1460 W. Evans St. <br />Florence, SC 29501 <br />20303 <br />10335 <br />A 1,000,000 <br />3587102512/31/201712/31/2018 1,000,000 <br />10,000 <br />1,000,000 <br />2,000,000 <br />2,000,000 <br />COMBINED TOTAL10,000,000 <br />1,000,000B <br />7358258112/31/201712/31/2018 <br />1,000,000A <br />7984554412/31/201712/31/2018 1,000,000 <br />10,000 <br />C <br />0196-1237212/31/201712/31/2018 500,000 <br />500,000 <br />500,000 <br />General Liability-Forms & Endorsements <br />Blanket Additional Insured on a Primary and Non-Contributory basis per carrier <br />form 80-02-2367 (05/07) <br />Additional Insured - Ongoing operations per carrier form 80-02-2305 (03/17) <br />Blanket Waiver of Subrogation per carrier form 80-02-2000 (04/01) <br />Per Location/Project Aggregate per carrier form 80-02-6554 (03/17) <br />SEE ATTACHED ACORD 101 <br />Orange County <br />PO Box 8181 <br />Hillsborough, NC 27278 <br />QUALAIR-01EWELLL <br />Insurance Office of America, Inc. <br />854 Washington Street NW <br />Suite 200 <br />Gainesville, GA 30501 <br />Lori Ewell <br />lori.ewell@ioausa.com <br />Federal Insurance Company <br />Great Northern Insurance Company <br />Bridgefield Casualty Insurance Company <br />X <br />X <br />X <br />X <br />X <br />X <br />X <br />X <br />DocuSign Envelope ID: 6CE9F4FB-27D4-4B9A-A269-DDC1952921CB