|
DocuSign Envelope ID: D776FCD3-A986-470D-9E2B-8853B19D52DF
<br /> JFWILKE-01 CLUCAS
<br /> '4C�/Za CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
<br /> 312912019
<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 INSUREII 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 /> PRODUCER CONTACT Cathleen Lucas
<br /> NAME:
<br /> Summers Thompson Lowry, Inc. PHONE FAX
<br /> 2113 Cameron Street (AIC,No,Ext):(919)969-5311 (Arc,No):(919)9424221
<br /> Suite 219 E-MAIL cathy@stlinsure.com
<br /> Raleigh, NC27605-1370 INSURER(S)AFFORDING COVERAGE NAIC*
<br /> INSURERA:The Charter Oak Fire Insurance Corn pany 25615
<br /> INSURED INSURERB:The Travelers Indemnity Company 25658
<br /> J.F.Wilkerson Contracting Co. Inc. INSURERC:The Travelers Property Casualty Insurance Company of America 255674
<br /> P.O. Box 183 INSURERD:St Paul Surplus Lines Insurance Company
<br /> Morrisville, NC 27560
<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 /> INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br /> LTR INSD WVD MMIDDNYYY MMIDDNYYY
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE X OCCUR C06B354615 4/1/2019 4/1/2020 DAMAGE TO RENTED 300,000
<br /> X PREMISES Ea occurrence $
<br /> MED EXP(Any one person) $ 10,000
<br /> PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PEP GENERAL AGGREGATE $ 2,000,000
<br /> POLICY T JjECT M LOC PRODUCTS-COMPIOPAGO $ 2,000,000
<br /> OTHER $
<br /> B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000
<br /> Ea accdent $
<br /> X ANY AUTO ON209577 4/1/2019 1/1/2020 BODILY INJURY(Per person) $
<br /> OWNED SCHEDULED
<br /> AUTOS ONLY AUTOS BODILY INJURY Per accident $
<br /> HIRED NON-OWNED PROPERTY DAMAGE
<br /> AUTOS ONLY AUTOS ONLY ( eracadent) $
<br /> C X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 6,000,000
<br /> EXCESS LIAB
<br /> CLAIMS-MADE CUP71<4053651926 4/1/2019 1/1/2020 AGGREGATE $
<br /> DIED I X I RETENTION$ 10,000 aggregate $ 6,000,000
<br /> C WORKERS COMPENSATION X PER OTH-
<br /> AND EMPLOYERS'LIABILITY STATUTE ER
<br /> YIN U B2J 614794 4/1/2019 111/2020 500,000
<br /> ANY PROPRI Rf NIA RfEXECUTIVE ❑ E L.EACH ACCIDENT $
<br /> OFFICERfMEMBMBER EXCLUDED?
<br /> (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 500,000
<br /> If yes,describe under 500,000
<br /> DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $
<br /> A Installation floater 660613715799 4/1/2019 1/1/2020 pump houses only 250,000
<br /> D Comm Pollution CC41M94021-18 4/1/2018 1/1/2020 Each Poll Condition 1,000,000
<br /> DESCRIPTION OF OPERATIONS r LOCATIONS r VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Blanket additional insured endorsement applies to general liability,to include completed operations, as regarded by written contract.
<br /> Project: Efland Sewer to Mebane Phase 2 Extension,Orange County,NC
<br /> Owners's Contract No.: CIP 30044
<br /> Engineer's Project No.: 16.01904
<br /> hfleming@orangecountync.gov,dale.schepers@mcgillengineers.com
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> Orange County, NC(owner)&McGill&Associates(Eng) ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> 131 West Margaret Lane
<br /> Hillsborough, NC 27278
<br /> AUTHORIZED REPRESENTATIVE
<br /> ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD
<br />
|