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DocuSign Envelope ID:5F379893-6C3D-49CA-AAAA-1A8324084F83 <br /> DATE(MM/DD/YYYY) <br /> CERTIFICATE OF LIABILITY INSURANCE <br /> 10/18/2019 <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 /> CONTACT <br /> PRODUCERHanover Excess&Surplus, Inc. NAME: PEGRAM PREVATTE INSURANCE <br /> PO Box12450 PHONE FAX <br /> WC, <br /> IC No Ext: 336-226-4044 A/C No: <br /> WILMINGTON,NC 28405 336-226-4039 <br /> E-MAIL <br /> ADDRESS: <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A: MESA UNDERWRITERS SPECIALTY INfii 36838 <br /> INSURED POYTHRESS,CINDY INSURERB: <br /> DBA POYTHRESS TENTS INSURER C: <br /> 2206 WAGONER RD <br /> GIBSONVILLE,NC 27249 INSURERD: <br /> INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 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 POLICYNUMBER MM/DD/YYYY MM/DD/YYYY <br /> A X COMMERCIAL GENERAL LIABILITY 1,000,000 <br /> EACH OCCURRENCE $ <br /> DAMAGE TO RENTED <br /> CLAIMS-MADE � OCCUR PREMISES(Ea occurrence) $ 100,000 <br /> MP0032004001951 06/18/2019 06/18/2020 <br /> MED EXP(Any one person) $ 5,000 <br /> PERSONAL&ADV INJURY $ 1,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 <br /> X POLICY PRO JECT ❑ LOC PRODUCTS-COMP/OPAGG $ 2,000,000 <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> Ea accident <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY Per accident <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB HCLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER <br /> ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBEREXCLUDED? N/A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> eductible:$ $D <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> TENTS,CHAIRS&TABLE RENTALS <br /> CERTIFICATE HOLDER CANCELLATION <br /> ORANGE COUNTY GOVERNMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> PO BOX 8181 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> HILLSBOROUGH, NC 27278 ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> 11 AAAAAA <br /> ©1988-2016 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br />