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ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />INSR ADDL SUBR
<br />LTR INSD WVD
<br />PRODUCER CONTACT
<br />NAME:
<br />FAXPHONE
<br />(A/C, No):(A/C, No, Ext):
<br />E-MAIL
<br />ADDRESS:
<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 />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 />EACH OCCURRENCE $
<br />DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)
<br />MED EXP (Any one person) $
<br />PERSONAL & ADV INJURY $
<br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $
<br />PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT
<br />OTHER:$
<br />COMBINED SINGLE LIMIT
<br />$(Ea accident)
<br />ANY AUTO BODILY INJURY (Per person) $
<br />OWNED SCHEDULED
<br />BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
<br />HIRED NON-OWNED
<br />PROPERTY DAMAGE
<br />$AUTOS ONLY AUTOS ONLY
<br />(Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $
<br />PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under
<br />E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />COMMERCIAL GENERAL LIABILITY
<br />Y / N
<br />N / A
<br />(Mandatory in NH)
<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 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.ACORD 25 (2016/03)
<br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
<br />$
<br />$
<br />$
<br />$
<br />$
<br />The ACORD name and logo are registered marks of ACORD
<br />8/6/2019
<br />(919) 969-5322 (919) 942-4221
<br />25674
<br />Custom Controls Unlimited Inc.
<br />2600 Garner Station Blvd
<br />Raleigh, NC 27603
<br />19070
<br />A 1,000,000
<br />X ZLP81M77236 4/3/2019 4/3/2020
<br />300,000
<br />10,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />EBL AGGREGATE 3,000,000
<br />1,000,000A
<br />BA9M503843 4/3/2019 4/3/2020
<br />5,000,000A
<br />X CUP9M506636 4/3/2019 4/3/2020
<br />10,000 5,000,000
<br />B
<br />X UB3J517642 4/3/2019 4/3/2020 1,000,000
<br />1,000,000
<br />1,000,000
<br />A Prof Liability ZPL31M77167 4/4/2019 Per Claim 1,000,000
<br />Orange County Planning and Inspections Department is listed as Additional Insured with respect to General Liability and Umbrella per written contract.
<br />Orange County
<br />Attn: Planning and Inspections Department
<br />Engineering Division
<br />PO Box 8181
<br />Hillsborough, NC 27278
<br />CUSTCON-01 DMASON
<br />Summers Thompson Lowry, Inc.
<br />2113 Cameron Street
<br />Suite 219
<br />Raleigh, NC 27605-1370
<br />Deborah Mason
<br />debbie@stlinsure.com
<br />The Travelers Property Casualty Insurance Company of America
<br />Standard Fire Insurance Company
<br />Aggregate
<br />X
<br />4/4/2020
<br />X
<br />X
<br />X
<br />X
<br />X
<br />X
<br />DocuSign Envelope ID: 80DF9584-550F-4149-B79B-E7660248041B
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