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INSR ADDLSUBRLTRINSR WVD
<br />DATE (MM/DD/YYYY)
<br />PRODUCER CONTACTNAME:
<br />FAXPHONE(A/C, No):(A/C, No, Ext):
<br />E-MAILADDRESS:
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)
<br />COMMERCIAL GENERAL LIABILITY
<br />AUTOMOBILE LIABILITY
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />AUTHORIZED REPRESENTATIVE
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />Y / N
<br />N / A
<br />(Mandatory in NH)
<br />ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?
<br />EACH OCCURRENCE $
<br />DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR
<br />MED EXP (Any one person) $
<br />PERSONAL & ADV INJURY $
<br />GENERAL AGGREGATE $
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP AGG $
<br />$
<br />PRO-
<br />OTHER:
<br />LOCJECT
<br />COMBINED SINGLE LIMIT $(Ea accident)
<br />BODILY INJURY (Per person) $ANY AUTO
<br />OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
<br />AUTOS ONLYHIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE $
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $
<br />$
<br />PER OTH-STATUTE ER
<br />E.L. EACH ACCIDENT $
<br />E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
<br />POLICY
<br />NON-OWNED
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<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 />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 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 any rights to the certificate holder in lieu of such endorsement(s).
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br />CERTIFICATE HOLDER CANCELLATION
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)
<br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE
<br />Valley Forge Insurance Co
<br />Great American Insurance Company
<br />National Fire Insurance Of Hartford
<br />Lexington Insurance Company
<br />7/09/2019
<br />Edgewood Partners Ins. Center
<br />2405 Satellite Blvd., Ste. 200
<br />Duluth, GA 30096
<br />770 232-0202
<br />Cartrina Richey
<br />678 475-3862 770 232-9202
<br />cartrina.richey@epicbrokers.com
<br />PENTA ENGINEERING GROUP, INC.,; A
<br />APPLIED TECHNICAL SERVICES, INC.;4000
<br />MILLER COURT WEST
<br />NORCROSS, GA 30071
<br />20508
<br />16691
<br />20478
<br />19437
<br />AX
<br />X
<br />XXX
<br />X X 6078554632
<br />Incl.Contractual
<br />07/15/2019 07/15/2020 1,000,000
<br />100,000
<br />15,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />C
<br />X
<br />XX
<br />X X 6078554596
<br />Comp/Coll Ded.
<br />$2,000
<br />07/15/2019 07/15/2020 1,000,000
<br />UNIM 100,000
<br />B XX
<br />X0
<br />TUU316247800
<br />Prof/Poll
<br />Not Included
<br />07/15/2019 07/15/2020 10,000,000
<br />10,000,000
<br />C
<br />N
<br />X 6078554615 07/15/2019 07/15/2020 X
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />D Professional/Poll
<br />Claims Made
<br />015719008 07/15/2019 07/15/2020 $10,000,000
<br />$250,000 Deductible
<br />ORANGE COUNTY
<br />PO BOX 8181
<br />HILLSBOROUGH, NC 27278-0000
<br />1 of 1#S1699264/M1693422
<br />APPLTECH1Client#: 43750
<br />CSIM1
<br />DocuSign Envelope ID: BDE3CDED-216E-4129-B5B9-ED290F2D91F9
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