2019-918-E AMS - Sasser ES Change Request 4

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DocuSign Envelope ID:AODF2D6C-3A18-4DOA-85FE-5237812F54C8 SASSCOM-01 DEIAKER ,d►C�►e�- CERTIFICATE OF LIABILITY INSURANCE DATE{MMI°DIYYYYJ 02107/2019 THIS CERTIFICATE IS 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 HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION 1S WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rig hts to the certificate holder in lieu of such endorsements). PRODUCER License#1000009384 Co NA TncT Hub International Carolinas PHONE EAx PO Box 939 Arc,No,Ft):(336)228-0541 wc,No:(868)590-4281 Burlington,NC 27216 E--MAIL INSURERS AFFORDING COVERAGE NAICR _ INSURER A:Selective Insurance Company of America 12572 INSURED INSURER B:Accident Fund General Insurance Company .12304 Sasser Companies Inc INSURER C: P 0 Box 10 INSURERD: Whitsett, NC 27377 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXPLTR L1AIrT5 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE l "I OCCUR S 2253759 0210112019 02/01/2020 DAMAGE TO RENTED $00,000 MED EXP(Any one arson s 15,000 PERSONAL&ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE a 3,000,000 POLICY PE OT LOG PRODUCTS-COMPIOP AGG 3,000,000 OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 x ANY AUTO S 2253759 02/01/2019 02/01/2020 BODILY INJURY Per arson OWNED SCHEDULED AUTOS ONLY AUTOS E BODILY INJURY Per accident AUTOS ONLY Al]TOS ONLY Pea'.'; nt AMAGE S S A )C UMRRELLA UAB x OCCUR EACH OCCURRENCE 10,000,000 EXCESS UAB CLAIMS-MADE S 2253759 02(01/2019 02/01/2020 AGGREGATE 10,000,000 QED RETENTION$ 13 WORKERS COMPENSATION PER 07H AND EMPLOYERS'LIABILITY YIN WCV6139124 02101/2019 02 O11202Q 1,000,000 � ANY PRO PRIETORIPARTNERIEXECuI IVE ❑ NIA E.L EACH ACCIDENT $ QFFIGERIM MBER EXCLUDED? 1'000,000 andatory�n NFi] E-L DISEASE-EA EMPLOYE $ Ifyes,describe under 11000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE"-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Orange County is an additional insured under the General Liability for work performed by the named insured for such additional insured,if required by contract signed by an authorized representative of the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange Count THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 y ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough,NC 27278 AUTHORIZED REPRESENTATIVE ACORD 25(2018103) 01988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD