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DocuSign Envelope ID:CB182934-0461-457E-A18F-D1E5A8C2A3B1 <br /> MARKTA OP ID: EC <br /> ,4cc�rrr� CERTIFICATE OF LIABILITY INSURANCE DA09/21/2016TE Y} <br /> �— 091211201s <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. It 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 endorsements. <br /> PRODUCER 'a°,Nr A:cT All'United Insurance Agency Co <br /> All United Insurance Agency pHolve $66-484-885fi FA7f <br /> 9716-B Rea Road,#123 A C—N ER1l. --- (AIC,No):866-362-9807 <br /> Charlotte,NC 28277 E-MAIL <br /> Al United Insurance Agency Co ADDRESS: <br /> INSURERS)AFFORDING COVERAGE NAIC# <br /> INSURER A.Main Street America Insurance 11066 <br /> INSURED Mark Tibbens DBA INSURER B:United Specialty Insurance Co. - <br /> Mark Tibbens Construction — <br /> 849 Moose Tracks Trail INSURER C:North Carolina Rating Bureau <br /> Cedar Grove,NC 27231 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 /> iLTR ----- TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS <br /> LTR POLICY NUMBER MMIODIYYYY MMIoDfYYYV <br /> GENERAL LIABILITY EACH OCCURRENCE s 300,00 <br /> -DAMAGE TO RENTE6 <br /> B X COMMERCKL GENERAL LIABILITY X CL1729215 1111812015 11118/2016 PREMISES Ea oaurrence S 500,04 <br /> CLAIMS-MADE OCCUR MED EXP(Any one person) $ 10,00 <br /> PERSONAL&A13V INJURY S 300,00 <br /> _ GENERAL AGGREGATE $ 600,00 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 600,00 <br /> X1 POLICY I PRQ LOC $ <br /> AUTOMOBILE LIABILITY CEOMBIN�EeD SINGLE LIMIT S 1,000,00 <br /> B X ANY AUTO B109698J 1111812016 1111812016 BODILY INJURY(Per person) $ALL OWNED SCHEDULED AUTOS AUTOS <br /> BODILY INJURY(Per accident) S <br /> _ <br /> NON DVNJEO —FRO PERT1f DAMAGE -$-. <br /> HIRED AUTOS AUTOS PER ACCIDEN <br /> UMBRELLA LIAR HoocuR EACH OCCURRENCE S <br /> EXCESS LIAR CLAIMS-MADE AGGREGATE $ <br /> DED I RETENTION _ --- S <br /> WORKERS COMPENSATION __ V�CSTATU- TH- <br /> AND EMPLOYERS`LIABILITY T.QRLf LI <br /> C ANY PROPRIETOWPARTNEWEXECUTIVE Y I N 41 B44722 0910612016 0910612017 E.L.EACH ACCIDENT S 100,00 <br /> OFFICERIMEMBEREXCLUDED? NIA — -- <br /> (Mandatary In NH) E.L.DISEASE-EA EMPLOYE $ 100,00 <br /> If es.descanbe under "----- <br /> DESCRIPTION OF OPERATIONS Mow E.L.DISEASE-POLICY LIMIT S 500,00 <br /> DESCRIPTION OF OPERATIONS]LOCATIONS I VEHICLES(Atlach ACORD 101,Additional Remarks Schedule,if more space is reclulredj <br /> Orange County is listed as additional Insured with respect to the General <br /> Liability Policy as required by written contract. <br /> CERTIFICATE HOLDER CANCELLATION <br /> ORANGE( <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> a County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Orange ty ACCORDANCE WITH THE POLICY PROVISIONS. <br /> PO BOX 8181 <br /> Hillsborough,NC 27278 AUTHORIZED REPRESENTATIVE <br /> All United Insurance Agency Co <br /> 0 1988-2010 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD <br />