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DocuSign Envelope ID: El9BECF9-5262-4897-B2D4-1 DA341 E7561 B
<br /> ACCN?{J CERTIFICATE OF LIABILITY INSURANCE 14;aq'ry'yyl
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF WORMATION ONLY ANO CONFERS NO PJGHTS UPON THE CERTIFICATE HOLDER. THIS
<br /> CERTIFICATE DOES NOT AFFIRMATlVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORI51*J�7 BY THE POLICES
<br /> BELOW- THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE Aw CONTRACT BETWEEN THE ISSUING INSURER(S), AtTfHORl7E-0
<br /> REPRESENTAT;Vp-OR PRODUQER,AND THE CER-IFICATZ HOLDER-
<br /> IMPORTANT: If ttva certificate holder is an ADDITIOMAE,INSURftl,the P6II1Wies}must be endorsed. I'f FAUBROGATION IS WAIVED, subject to the
<br /> #errs and condlllarrs of the Policy, certal.n Policies may require an andorsement A statement On this cartirficate does riot confer rights to the
<br /> Lartificain holder Irr lieu of such endorsenlengt,)-
<br /> PRooucea Greg LopLeman, CPCULanr+nlan
<br /> tate Farm In$urance PHONE
<br /> E,RI�979- 33-7T11 1NC Nor:919=9r33.77t3
<br /> J=�+51L
<br /> 1134 NC Hwy 541N o1 ss:Gre
<br /> g.LWwan-W3LQSt2ti�tatm.o�m_
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<br /> arrboro. NC 27510 weJC M
<br /> IwsuRER a:S4 ie Fame Fire and Pasuahy Co npqnv #3
<br /> IH3�IRF,p RILEY SURVUING PA WSUMER B:SWa Farm M*M1 Auwrnoeile Ir►surarrta co!Tmenv T8
<br /> STE 100E INSUAERC!
<br /> 3326 DURHAM CHAPEL HJLL 8LVD 1M9Ld4[atD-
<br /> DURHAM NC 27707- 695 IN�LMiERE:
<br /> MISUREk F• -
<br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br /> THIS 1S TO CERTIFY THAT FHE POLICE.$ OF INSURANCE LISTED SELOWV HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br /> INDICATE[]- NCTWIrHSTANDING ANY RFOLIIREMENT, TEW OR CC1401TION OF ANY CONTRACT OR OTHER DOCUMENT WrrF1 Rk$PECT To V01ICH THIS
<br /> CE MFICATE MAY BE; ISSUED OR MAY PERTAi . THE INSURANCE AFFC4MF,) BY THE POLICII±S DESCRQEO HEFM14 1$ SUBJECT TO ALI, THE TEfWS,
<br /> EXQL,l$IONS AND CONDITIONS OF SUCH POLICIES,LIMITS SL CWN MAY HAVE BEEN REDUC;FQ Sy PAID CLAIMS,
<br /> LV TYPEDFINSURAIpE aoL346Fk TfGTEFF PpLlcr p
<br /> P64�CY NUA16E72 Si11f3
<br /> GENERAL LIA13NMY Y ❑� 9$-CCY,7_OU5$ =IN2*19 0=0=20 EACHODrMxRENCE $ 9.Od0.OP4
<br /> C0G4dF.RCI+,L GENERAL LIAI$IUTY
<br /> !',�ekWES tEs ooagrm $ W0,000
<br /> CLAIMS-NE,4aE OCCURA+EaIXP(,aycnePevecn�i 5 5,000
<br /> PERSONA{t.ADV INJURY _ $ 1.0f 0.000
<br /> �- CLENERALAGGRF,CATE L 2,00 .Wo
<br /> G€ML AGGREr AT=LN{IT APPLI_Ffi PER: FROUMM L COMPIOP AGG i 2,000-000
<br /> } I PDuiCY Y F;'ELI
<br /> 4 C
<br /> B nu MLE UAMLmr I U71 9T d�f33D 33 1 OJ3012ff7 B 1 W34J2419 I LE ulna $
<br /> AHYAtJTO BOULY3M,ILIRY(Ref puro $ 500,000
<br /> ,+LTC)15 4 SCMEDALMMJLEd �FAM,(INARY{peromedwd)
<br /> �.IJTOti ALIfO° S SOIJ,OD4
<br /> HIRED AUTC6 }( NON-WMF.p —
<br /> AUTOS
<br /> ��� S 100,000
<br /> S
<br /> f{ UMBREL
<br /> LA OCCUR 42-0-
<br /> CI�pP.E}1CC S 1.000,044
<br /> EXCE5 93•Gi4t-1S19-1 0819W0118 ..
<br /> ClAlr.,$-HRQE ATE S 1.000-000
<br /> oFr+ CNI74,N5 10,OOQ -
<br /> rR
<br /> A I WORKERSCOMPENSATJON - o+J1D EMPLUTERIX L"MffY TONAWY PROPRMTORPMR1NCWIEXECtITIVEN,4CG14ENr $oFflCErnnEMBEREXCLUOEW M1A 93•CV-R463-3 02020020111 02170i2d
<br /> {Man�6ory In NMt E.L.Dh3 E-E4 EMPLOYEE S 1,009,4dd
<br /> a YBe,deseritg prQg,
<br /> E.L.DISEASE-r'(L,kICY LIMIT-F-
<br /> 1,00¢,q(r0
<br /> I
<br /> bEWRWTIOw OF OPGRAT,quS a LOCATIONS ewr;HICLJES{Avmeh ACORD 101.Ad=i al R*.na.ha Schedula.it R54fB SpLam is mgUkVq
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Orange County SHOULD o T Il ADOV'E DESCRIBED POUMES BE CANCELLED BEFORE
<br /> Tt� 8XP1 N DATIE THEREOF, N#ti7CE VWLL BE DELIVERED IN
<br /> PO Box 8181 ACCORD CE THE POLICY PROVISIONS-
<br /> Hillsborough, NC 27278
<br /> AMMORUEv TA
<br /> e 1988-2010 ACORD CORK AT N= All rights reserved.
<br /> ACORD 26 J2010;05) The ACORD name and logo are reg-mmired marks of ACORD f001466 132849.6 1 t-1 01a
<br />
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