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DATE (MM/DD/YYYY)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 be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />CONTACTPRODUCERNAME: <br />FAXPHONE(A/C, No):(A/C, No, Ext): <br />E-MAILADDRESS: <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURER A : <br />INSURED INSURER B : <br />INSURER C : <br />INSURER D : <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 />ADDL SUBRINSR POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITSPOLICY NUMBERLTR (MM/DD/YYYY) (MM/DD/YYYY)INSD WVD <br />COMMERCIAL GENERAL LIABILITY 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 AGG $JECT <br />$OTHER: <br />COMBINED SINGLE LIMITAUTOMOBILE LIABILITY $(Ea accident) <br />BODILY INJURY (Per person) $ANY AUTO <br />ALL OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS AUTOSNON-OWNED PROPERTY DAMAGE $HIRED AUTOS (Per accident)AUTOS <br />$ <br />UMBRELLA LIAB EACH OCCURRENCE $OCCUR <br />EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br />$DED RETENTION $ <br />PER OTH-WORKERS COMPENSATION STATUTE ERAND EMPLOYERS' LIABILITY Y / NANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $N / AOFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $ <br />If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <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 />AUTHORIZED REPRESENTATIVE <br />© 1988-2014 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01) <br />PASCH-1 OP ID: LP <br />11/12/2019 <br />Christopher Ives RubishHigh & Rubish Insurance Agency <br />P.O. Box 30406015 Farrington Rd. Ste 101Chapel Hill, NC 27517 <br />Christopher Ives Rubish <br />919-913-1144 919-913-1155 <br />chrisr@highandrubish.com <br />Erie Insurance Exchange 26271 <br />Dalton M Paschall <br />2718 Sparger Rd <br />Durham, NC 27705 <br />AX 2,000,000 <br />X Q341421296 10/14/2019 10/14/2020 2,000,000 <br />5,000 <br />2,000,000 <br />4,000,000 <br />X 4,000,000 <br />ORANGE1 <br />Orange County Government <br />PO Box 17177 <br />Chapel Hill, NC 27516 <br />DocuSign Envelope ID: D5FF8A50-5565-44A9-8357-962FCFB87527