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DocuSign Envelope ID:76865915-80B4-4DED-A27B-62FD8E3D323A <br /> AC Rom® CERTIFICATE OF LIABILITY INSURANCE DATE <br /> A EPAM0211 z "� <br /> O 19 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS <br /> CERTIFICATE DOES NOT AFFI RMATIVE LY 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 INSURERS),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 previsions or be endorsed- <br /> If SUBROGATION IS WAIVED,subject to the terms and conditioms 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 CN FACT Amy Mies <br /> Piedmont Triad Insurance PHONE (336)282-5555 FAx Al (336)282 5781 <br /> No <br /> 7 Battleground Ct Ste 224 E-MAIL amy@ptageney.com <br /> INSURERS)AFFORDING COVERACE NAIC q <br /> Greensboro NC 27408 INSURERA: Erie Indemnity Company 12345 <br /> INSURED INSURER B <br /> Harold Summey Jr INSURER c_ <br /> 2805 Miller Rd INSURER D <br /> INSURER E- <br /> Hillsborough NC 27514 INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: CL1912320157 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 /> LTR TYPE OF INSURANCE INSD ViND POLICY NUMBER POLICY EFF POLICY EXP L"ATS <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000.000 <br /> AMAGE TO RENTED 1,000,000 <br /> CLAIMS-MADE OCCUR PREMISES Ea occurrence $ <br /> MED EXP[Arty one person] $ 5,000 <br /> A Q35-1221163 01123/2019 1111212019 pERSDNALBAW INJURY g 1,000 <br /> GEN•LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000.000 <br /> RO-POLICY ❑JPECT ❑LOC PRODUCTS-COMPIOPAGG $ 2•00U•006 <br /> OTHER $ <br /> AUTOMOBILE LIABILITY comeiNEDSINGLE LIMIT $ 1,000,000 <br /> Ea aoudem <br /> ANYAUTO BODILY INJURY(Per person) $ <br /> A OWNED SCHEDULED 011-1240037 11/12/2018 11/12/2019 BODILY INJURY(Per wzoent) $ <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY Per ac Ident <br /> Underinsured motorist BI s i,000,000 <br /> UMBRELLA LIAB OCCUR EAOH OCCURRENCE $ <br /> 4 EXCESS LIAR HCLAIM"ADE AGGREGATE $ <br /> DE RETENTION$ $ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY YIN STATUTE ER <br /> ANY PROPRIETORIPARTNERIE7CECUTIVE ❑ N rA E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED? <br /> JWVWxb"In NH) E.L.DISEASE-EA EMPLOYEE S <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Addidonal Remarks Schedule,may 4e aft0ed H mom space Is required) <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 ACCORDANCE VVITH THE POLICY PROVISIONS. <br /> PO Box 8181 <br /> AUTHORIZED REPRESENTATIVE <br /> Hillsborough NC 27278 <br /> Q ISM2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(201W03) The ACORD name and logo are registered marks ofACORD <br />