2021-207-E-AMS-ASJ Wilson Construction-Board of Elections-Provide and install 3 well points

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DocuSign Envelope ID:2BBAA47C-8833-44D1-93B9-43EOEOA7B240 DATE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 01/06/2021 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 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 Jen Shon NAME: Pelnik Insurance PHONE (g19)459-8000 FAX (866)714-3576 A/C No Ext: A/C,No): 100 Ridgeview Drive E-MAIL Jen.Shon@pelnik.com ADDRESS: Suite 100 INSURER(S)AFFORDING COVERAGE NAIC# Cary NC 27511 INSURERA: West Bend Mutual Ins Co 15350 INSURED INSURER B: ASJ Wilson Construction LLC INSURER C: 415 Pisgah Church Rd INSURER D: PMB 128 INSURER E: Greensboro NC 27455 INSURER F: COVERAGES CERTIFICATE NUMBER: CL211620837 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 TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PRIM SES Ea :NcE ence $ 300,000 MED EXP(Any one person) $ 5,000 A A826708 01/06/2021 01/06/2022 PERSONAL&ADV INJURY $ 1,000,000 MOTHER LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED A826708 01/06/2021 01/06/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident Uninsured motorist $ 1,000,000 UMBRELLALIAB 4,000,000 OCCUR EACH OCCURRENCE $ A EXCESS LAB CLAIMS-MADE A826708 01/06/2021 01/06/2022 AGGREGATE $ 4,000,000 DED I X1 RETENTION $ 0 $ WORKERS COMPENSATION X STATUTE EREIR H AND EMPLOYERS'LIABILITY Y/N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ A OFFICER/MEMBEREXCLUDED? NIA Y A823975 01/06/2021 01/06/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) A Waiver of Subrogation applies in favor of the Certificate Holder with respects to Workers'Compensation&Employer's Liability policy when required by written contract,executed prior to loss. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Orange County ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough NC 27278 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD