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DocuSign Envelope ID:7186CDD6-CO92-419B-9B63-99A79E1E4846
<br /> ALPHAND-01 LHAMLET
<br /> CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
<br /> 7/6/2020
<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 /> PRODUCER CONTACT Lori F. Hamlet
<br /> NAME:
<br /> Trisure,an Alera Group Company PHONE FAX
<br /> 4325 Lake Boone Trail,Suite 200 (A/C,No,Ext): (919)469-2473 (AIC,No):(919)467-4987
<br /> Raleigh,NC 27607 ADDARIESS:(hamlet@trisure.com
<br /> INSURERS AFFORDING COVERAGE NAIC#
<br /> INSURER A:Travelers Indernity Company of America The 25666
<br /> INSURED INSURER B:Travelers Property Casualty Company of America 25674
<br /> Alpha and Omega Group PC INSURER C:Travelers Casualty and Surety Company of America 31194
<br /> Ted Bartelt
<br /> 4601 Lake Boone Trail Ste 3C INSURER D:
<br /> Raleigh,INC 27607 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 NUMBER POLICY EFF POLICY EXP LIMITS
<br /> LTR IN SD WVD MM DD YYY MM DD YYY
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE X OCCUR 6801JO407OA20 5/19/2020 5/19/2021 DAMAGE TO RENTED 1,000,000
<br /> X PREMISES Ea occurrence $
<br /> MED EXP(Any oneperson) $ 5,000
<br /> PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> POLICY ] JEC 1:1LOC PRODUCTS-COMP/OP AGG $ 2,000,000
<br /> OTHER: $
<br /> B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000
<br /> Ea accident $
<br /> X ANY AUTO BA4F99976620 5/19/2020 5/19/2021 BODILY INJURY Perperson) $
<br /> OWNED SCHEDULED
<br /> AUTOS ONLY AUTOS BODILY INJURY Per accident $
<br /> HIRED NON-OWNED PROPERTY DAMAGE
<br /> AUTOS ONLY AUTOS ONLY Per accident $
<br /> L $
<br /> B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000
<br /> EXCESS LIAB CLAIMS-MADE CUP4F99980920 5/19/2020 5/19/2021 AGGREGATE $ 5,000,000
<br /> DED X RETENTION$ 10,000 $
<br /> A WORKERS COMPENSATION X PER OTH-
<br /> AND EMPLOYERS'LIABILITY STATUTE ER
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X UB9K60615820 5/19/2020 5/19/2021 1,000,000
<br /> OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> If yes,describe under 1,000,000
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
<br /> C Professional Liab 106741445R3 5/19/2020 5/19/2021 Limit 1,000,000
<br /> C Professional Liab 106741445R3 5/19/2020 5/19/2021 Aggregate 2,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Operations of the Named Insured covered by the above referenced policies.
<br /> Orange County,its officers,official agents and employees are included as additional insureds with respects to General Liability if required by written contract.
<br /> A waiver of subrogation applies in favor of Orange County,its officers,official agents and employees with respects to Workers Compensation if required by
<br /> written contract.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> Orange Count THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> 9 y ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Attn: Christopher Sandt,Planning&Inspections Dept.
<br /> csandt@orangecountync.gov
<br /> PO Box 8181 AUTHORIZED REPRESENTATIVE
<br /> Hillsborough,NC 27278 t(] 4- ywnju-
<br /> ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD
<br />
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