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DocuSign Envelope ID:6228C379-87D0-46DE-BCA8-2EFF9ED2282F <br /> ACC> CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> 12/02/2020 <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 poliey(ies)must have ADDITIONAL INSURED provisions or be endorsed. <br /> If SUBROGATION 1S 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 <br /> NAME: Amy Mlles <br /> Piedmont Triad Insurance Agency PHONE FAX <br /> (336)282-5555 plc No:(336)282-5781 <br /> 7 Battleground Ct, Suite 224 aoDR'E s: amy@ptiagenov.com <br /> Greensboro, NC 27408 INSURERS AFFORDING COVERAGE NAIC# <br /> INSURED INSURERA: Erie Indemnity Cqmpany 26271 <br /> INSURER B: <br /> Harold Summey Jr INSURERC: <br /> 2806 Miller Rd INSURERD: <br /> Hillsborough, NC 27278-8487 INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 00021701-242869 REVISION NUMBER: 33 <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 ADDL SUBR POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSD POLICY NUMBER MIDDIYYYY MM/DDlYYYY LIMITS <br /> A x COMMERCIAL GENERAL LIABILITY 036-1221163 11/12/2020 11/12/2021 EACH OCCURRENCE $ 1,600,000 <br /> CLAIMS-MADE Fk OCCUR DAMAGE TO RENTED <br /> PREMISES Ea occurrence $ 1000,000 <br /> MED EXP(Any one person) $ 000 <br /> PERSONAL&ADV INJURY $ 1,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2 00,000 <br /> NX POLICY❑JECOT- LOCPRODUCTS-COMPlOP AGG $ 2 000000 <br /> OTHER: $ <br /> A AUTOMOBILE LIABILITY 011-1240037 11/12/2020 11112/2021 EOac den SINGLE LIMIT I. <br /> 11000,000 <br /> ANY AUTO OWNED SCHEDULED BODILY INJURY(Per person) $ <br /> - <br /> AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ <br /> HIRED AUTOSNON-OWNEDONLY <br /> PROPERTY DAMAGE $ <br /> IX <br /> AUTOS ONLY X AUTOS ONLY Per accident <br /> Underinsured mo $ 1000000 <br /> UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION $ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER _ <br /> ANY PROPRIETORlPARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? ❑ N/A $ <br /> (Mandatory in <br /> If E.L.DISEASE-EA EMPLOYEE $ <br /> end <br /> DESs,describe under CRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Orange County THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> PO Box 8181 <br /> Hillsborough, NC 27278 AUTOOR� --_ <br /> LMC) <br /> ©1988.2016 ACORD CORPORATION. All rights reserved. <br /> ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD <br /> Printed by LMC on December 02,2020 at 05:09PM <br />