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DocuSign Envelope ID:C3BC20BE-4177-4E09-B25F-8E12C5916446 <br /> DATE(MM10D1YYYY) <br /> ACOR" CERTIFICATE OF LIABILITY INSURANCE <br /> 64_ � 1 10/4/201 S <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(iesy 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 <br /> NAME: Lynne Meyer,CIC,CPIW,AINS _ <br /> Marsh&McLennan Agency LLC PISONE r FAX <br /> 3625 North Elm St co No.Ext):336-346-1302 fwc,Noy:336-346-1397 <br /> Greensboro NC 27455 ADneess; L nne.Me er marshmma.com <br /> INSURERS AFFORDING COVERAGE_ _ _ - NAIL NJ <br /> INsuRER A.Builders Premier Insurance Company 13036 <br /> INSURED BIRSI-2 INSURER B!Columbia Casualty Company 31127 <br /> Inc. <br /> Mr. Raven Broeker INSURERC:Builders Mutual Insurance Company 10844 <br /> Mr. R <br /> PO Box 36197 INSURER 0; <br /> Greensboro NC 2741 M197 INSURER E- <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER.,1625434416 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 /> INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS <br /> LTR POLICYNUMBER MMIO MMIOD <br /> A X COMMERCIAL GENERAL LIABILITY PCP0003W SIIP01 B 511r2019 EACH OCCURRENCE S 1,OD0,0DO <br /> DAMAGE TO RENTED <br /> CLAIMS-MADE X OCCUR PREMISES.(Ea cccuTence,� $100,000 <br /> MEP EXP(Any one person) $5,000 <br /> PERSONAL&ADV INJURY $1,D00,00D <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2.000.000 <br /> _ POLICY[�],ECT1:1 Loc PRODUCTS-COMPIOP AGO $2,000,ODD <br /> OTHER: S <br /> A AUTOMOBILE LIABILITY PCAfl016423 511R018 SMR019 COEa SIN:nlM6INER GiNGLE LIMIT $1 oDD am <br /> x ANY AUTO BODILY INJURY(Par parsofl) $ <br /> OWNED SCHEDULED BODILY INJURY(Per aecddent) S <br /> AUTOS ONLY AUTOS <br /> X HIRED x NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY APer aocddenf ._ <br /> Corn fCoII Dad T $1,000f1,D00 <br /> C X UMBRELLA LIAR x OCCUR MU80001286 5Ml201 B 511/2019 EACH OCCURRENCE $5,OOD,000 <br /> EKG ESS LIAR CLAIMS-MADE AGGREGATE S 5,000,000 <br /> OED x RETENTIONS lo.00n $ --- <br /> A WORKERS COMPENSATION pWC1000290013 SM121318 FOIN019 x PER <br /> AND EMPLOYERS'LIABILITY YIN STATUTE ER <br /> ANYPROPRIETOPJPARTNERfEXECLMVE ❑ NIA E.L.EACH ACCIDENT $1,000,000 <br /> OFFICE RIMEMB ER EXCLUDED? _ <br /> (Mandatary(a NH) E.L.DISEASE-EA EMPLOYEE S 1,OD,aco <br /> If yyS6 describe under --- <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 <br /> A Rental Eqquippment PCPD093632 M12018 511=19 7fi9,6pD <br /> B E&OlPdlutian CE0591855996 5/1/2018 5M12019 1,000'am <br /> DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES(ACORD f01,Addilfonaf Remarks Sched u}n,may be allached ff main space is r"ulred) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLFD BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Orange County <br /> PO Box 85181 AU ORIZEDREPRESENTATN <br /> Hillsborough NC 27278 I7 ) R <br /> R�r � <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD <br />