2020-004-E Planning - In Water Services LakeOrange intake tower service

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DocuSign Envelope ID:884B2CFE-2DE5-44E8-9F7A-8208DA7367FC I OP ID: SB .4C"J?" (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCEFDATE12/10/2019 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 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 NAME: Sandra Berry Southeastern Agency Group,lnc. PHONE FAX 1501 Highwoods Blvd.,St#402 A/C No Ext:336-218-7470 A/c,No): 336-218-7487 Greensboro,NC 27410 E-MAIL ber Travis Ketron ADDRESS:s ry@sa gnc.com PRODUCER INWAT-1 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED In Water Services Co, Inc INSURERA:WC Assigned Risk/Travelers 3683 Southeast School Rd INSURER B:Berkley Fire&Marine 38911 Greensboro, NC 27406 INSURER C:Pennsylvania National 14990 INSURER D: 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 CONTRACT OR 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 ADDTYPE OF INSURANCE L SUBR POLICY EFF POLICY EXP LIMITS LTR R WV POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO REN =-U-- COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY F7 PROEC� F7 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00 C X ANY AUTO AU9 0676239 09/24/2019 09/24/2020 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (PER ACCIDENT) $ X NON-OWNED AUTOS $ C X1 ded 250/500 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVEY/N 6JUB-02E36278-8-19 09/24/2019 09/24/2020 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED' F7 N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 B Rented and Leased MIM 1016903-52 09/24/2019 09/24/2020 Limit 300,000 Equipment Ded 1,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Orange Lake Project CERTIFICATE HOLDER CANCELLATION ORANGEC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange Count Planning d THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g y g an ACCORDANCE WITH THE POLICY PROVISIONS. Inspections Department PO Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Travis Ketron ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD