2019-616-E County Mgr - NC Coalition to End Homelessness HMIS database

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DocuSign Envelope ID: BDDDD430-E4C8-4429-B240-4E14BF7C5CC7 AC" CERTIFICATE OF LIABILITY INSURANCE FDATEIMMIIXNYYYY) 1 2/1 312 0 1 8 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE BOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT DAVID BRAS WELL INSURE PHONE 919 781-1115 A1C No; (919)783.6427 AIC No. D Ext: ( 2607 GLENWOOD AVENUE(27608) L-MAIL s: DBRASWELL(PINSURE-NC.COM ADDRE PO BOX 31508 INS URERS}AFFORDING COVERAGE NAIC N RALEIGH NC 27522 INSURERA; AUTO-OWNERS INSURANCE COMPANY 18988 INSURED INSURER B; TRAVELERS INDEMNITY COMPANY OF AMERICA 25666 NORTH CAROLINA COALITION TO END HOMELESSNESS INC INSURER C; PO BOX 27692 INSURER D INSURER E; RALEIGH NC 27611-7692 INSURER F: COVERAGES CERTIFICATE NUMBER: STD 2019.20 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNSR AuDrTmm POLICY EFF P LICY LTR TYPE OF INSURANCE INSD WVD POL[CY NUMBER MMIDDIYYYY MMfDD1YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE DAMAGE TO RENT ED OCCUR PREMISES Ea occurrence $ 300,000 MED EXP Any one person] $ 10.000 A Y Y 35658183 01112=19 01/12/2020 PERSONAL&ACV INJURY $ 1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000 POLICY 0 PRO -PRODUCTS COMP1OP AGG $JECT LDC 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Es aceldent ANY AUTO BODILY INJURY(Per parson) $ OWNED SCHEDULED BODILY INJURY ] AUTOS ONLY AUTOS (Par accident S HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per aecldent E 5 UMBRELLA MAD OCCUR EACH OCCURRENCE $ EXCESS UAB HCLAIMS-MADE AGGREGATE S DEO I I RETENTIONS I I S WORKERS COMPENSATION PER Or"- AND EMPLOYERS'LIABILITY YIN x STATUE ER B ANY PROPRIETORIPARTNERIEXECUIIVE NIA Y UB-OK4S4798-19-d2 01/30/2019 01I3012020 E,L.EACH ACCIDENT $ 100.000 OFFICERIMEMBER EXCLUDED? IMandatory In NN)If yes,describe under E.L.DISEASE-EA EMPLOYEE g 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT g 504,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 1111,Additional Remarks Schndufe,may be attached it more space Is required) IF REQUIRED IN A WRITTEN CONTRACT,LANDLORD(MARBLE EMPIRE PROPERTIES LLC)AND MANAGER(EMPIRE HISTORIC DEVELOPMENTS INC)ARE ADDITIONAL INSUREDS FOR GENERAL LIABILITY AS PER FORM 65091 05117 ATTACHED. SUBROGATION IS WAIVED IN FAVOR OF LANDLORD AS PER FORM 55091 05117 AND FORM WC 00 03 13(00)ATTACHED. RE:BUILDING LEASE AT 310 N HARRINGTON STREET,RALEIGH,NC 27603 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA7ION DATE THEREOF,NOTICE WILL BE DELIVERED IN MARBLE EMPIRE PROPERTIES LLC AND EMPIRE HISTORIC ACCORDANCE WIT"THE POLICY PROVISIONS. DEVELOPMENTS INC 133 FAYETTEVILLE ST BTH FL AUTHORIZED REPRESENTATIVE RALEIGH NC 27601 V4e 9)1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD