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DocuSign Envelope ID:67CO9E91-68ED-441D-8F813-091C77422DBD <br /> 78/7/2019 <br /> E(MM/DD/YYYY) <br /> CERTIFICATE OF LIABILITY INSURANCE <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 rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> NAME: Tammy L.Coolidge,CIC,CISR,ACSR <br /> Marsh &McLennan Agency LLC PHONE FAX <br /> 2301 Sugar Bush Road, Suite 600 A/c No Ext:919 719-9861 A/c No):212-607-6564 <br /> Raleigh NC 27612 ADDRESS: Tammy.Coolidge@marshmma.com <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A:Selective Ins Co of the SEast 39926 <br /> INSURED ROYAL-5 INSURER B: Builders Mutual Ins.CO. 10844 <br /> Associates, Inc. <br /> Attn:ttn: Donn Eidson -CEO INSURER C:Selective Insurance Co of the Southeast 39926 <br /> D <br /> P. O. Box 91145 INSURER D: <br /> Raleigh NC 27675-1145 INSURERE: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER:1341070052 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 IN SD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY <br /> C X COMMERCIAL GENERAL LIABILITY S1931429 4/1/2019 4/1/2020 EACH OCCURRENCE $1,000,000 <br /> CLAIMS-MADE OCCUR DAMAGE TO RENTED PREM SES(Ea occurrrence $500,000 <br /> MED EXP(Any one person) $15,000 <br /> PERSONAL&ADV INJURY $1,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 <br /> POLICY� PRO- � LOC PRODUCTS-COMP/OP AGG $3,000,000 <br /> OTHER: $ <br /> C AUTOMOBILE LIABILITY S1931429 4/1/2019 4/1/2020 COMBINED SINGLE LIMIT $1,000,000 <br /> Ea accident <br /> X ANY AUTO BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> X HIRED X NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY Per accident <br /> X Hired Auto Hired Physical Damage $$75,000 <br /> C X UMBRELLA LIAB X OCCUR S1931429 4/1/2019 4/1/2020 EACH OCCURRENCE $5,000,000 <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 <br /> DIED X RETENTION$ $ <br /> B WORKERS COMPENSATION WCP102439605 4/1/2019 4/1/2020 X PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER <br /> ANYPROPRIETOR/PARTNER/EXECUTIVE NIA <br /> E.L.EACH ACCIDENT $1,000,000 <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 <br /> A Inland Marine S1931429 4/1/2019 4/1/2020 Leased Eq 60,000 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> Project Reference: 4-5258 NC Orange Co Parks&Rec Gym <br /> Orange County Government is included as additional insured with regards to general liability as stated in the policy language with written contract prior to any <br /> loss. <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 /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Orange County Government <br /> PO Box 8181 AUTHORIZED REPRESENTATIVE <br /> Hillsborough NC 27278 <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br /> THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE <br />