Orange County NC Website
DocuSign Envelope ID:A5C5852A-9983-46OF-A7BA-FA37B81AA9F4 <br /> DATE(MMIDDIYYYY) <br /> Ac"R" CERTIFICATE OF LIABILITY INSURANCE <br /> 6/29/2016 <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 /> PRODUCER CONTACT Crystal Ireland <br /> NAME; rY <br /> Business Insurers of Carolinas PHONE )(0. (919)968-4611 CpAj ,Na).(9191968-8991 <br /> 800 Eastorme Drive, Suite 208 t. MI.A'M -s:cireland@business-insurers,coin <br /> PO Box 2536 --- INSURERS)AFFORDING COVERAGE- -- — NAIC A <br /> Chapel Hill NC 27515-2536 INSURERA:Penn National ins. Companies 14990 <br /> INSURED INSURER 0arid efield Casualty Insurance 10335 <br /> Warren-Hay Mechanical. Contractors Inc INSURER c Philadelphia_Insurance Comp 18058 <br /> Sheet Metal Duct Suppliers LLC INSURERD: <br /> PO BOX 818 INSURER.E <br /> Hillsborough NC 27278 INSURER F: - - - <br /> COVERAGES CERTIFICATE NUMBER:CL161514307 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 POLI CIES.LIMITS SHOWN MAY HAVE BEEN REDU CED BY PAID CLAIMS. <br /> INSR TYPE OF INSURANCE AL SOBR POLICY EFF POLICY EXP LIMITS <br /> LTR d 8. Df D POLICY NUMBER MMiOYYYY) 4MM7D0 <br /> tXCOMMFRCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 <br /> _UAMAGERENED <br /> A CLAIMS-MADE L.XJ OCCUR PREMSES(Ea occu ence. S 100,000 <br /> CX90726312 12/31/2015 12/31/2016 MEDEXP[Anyonelrersan� S 10,000 <br /> I PERSONAL&ADV INJURY S 1,000,000 <br /> GEN`L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 <br /> X POLICY El vei LOC PRODUCTS-COMP/GP AGG $ 2,000,000 <br /> OTHER: S <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 <br /> Ea accidend <br /> A X ANY AUTO BODILY INJURY(Per Person) S <br /> ALLOYMED SCHEDULED AX90726312 12/31/2015 12/31/2016 BODILY INJURY(Per accideni) S <br /> AUTOS _ AUTOS _ <br /> HIRED AUTOS NON4DNMEO PROPERTY DAMAGE S <br /> AUTOS e d <br /> Endorsements $ <br /> X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 3 MOO j 000 <br /> A EXCESS LIAH CLAIMS-MADE AGGREGATE $ 3,000,000 <br /> DED RETENTIONS UL90726312 12/31/2015 12/31/2016 S <br /> WORKERS COMPENSATION X PER OTH- <br /> AND EMPLOYERS'LIABILITY YIN STATUTE ER <br /> ANY PROPRIETONPARTNER/EXECUTIVE ��T�N f R F-L.EACH ACCIDENT $ 500,000 <br /> S OFFICERIMEMBER EXCLUDED? I`" I. <br /> (Mandatory In NH) 0196-40173 12/31/2015 12/31/2016 El,DISEASE-EAEMPLOYE S 500,000 <br /> If yyes,describe under <br /> 0ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 <br /> C RESD1108639 12/31/2015 12/31/2016 <br /> DESCRIPTION OF OPERATIONS!LOCATIONS 1 VEHICLES(ACORD 101,Addltinnal Remarks Schedule,may be attached it more space is required) <br /> CERTIFICATE BOLDER CANCELLATION <br /> abarnes@orangecountync.gov <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Grange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> PO B0X 8181 ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Hillsborough, NC 27278 <br /> AUTHORIZED REPRESENTATIVE <br /> �rf <br /> J Knauff, T'V/IRELOi -- <br /> 01988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD <br /> IN502547oI4 o <br />