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ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? <br />INSR ADDL SUBR <br />LTR INSD WVD <br />PRODUCER CONTACT <br />NAME: <br />FAXPHONE <br />(A/C, No):(A/C, No, Ext): <br />E-MAIL <br />ADDRESS: <br />INSURER A : <br />INSURED INSURER B : <br />INSURER C : <br />INSURER D : <br />INSURER E : <br />INSURER F : <br />POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) <br />AUTOMOBILE LIABILITY <br />UMBRELLA LIAB <br />EXCESS LIAB <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />AUTHORIZED REPRESENTATIVE <br />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 AGGJECT <br />OTHER:$ <br />COMBINED SINGLE LIMIT <br />$(Ea accident) <br />ANY AUTO BODILY INJURY (Per person)$ <br />OWNED SCHEDULED <br />BODILY INJURY (Per accident)$AUTOS ONLY AUTOS <br />HIRED NON-OWNED PROPERTY DAMAGE <br />$AUTOS ONLY AUTOS ONLY (Per accident) <br />$ <br />OCCUR EACH OCCURRENCE <br />CLAIMS-MADE AGGREGATE $ <br />DED RETENTION $ <br />PER OTH- <br />STATUTE ER <br />E.L. EACH ACCIDENT <br />E.L. DISEASE - EA EMPLOYEE $ <br />If yes, describe under <br />E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />COMMERCIAL GENERAL LIABILITY <br />Y / N <br />N / A <br />(Mandatory in NH) <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 />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 />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 />COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: <br />CERTIFICATE HOLDER CANCELLATION <br />© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) <br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) <br />$ <br />$ <br />$ <br />$ <br />$ <br />The ACORD name and logo are registered marks of ACORD <br />Scott Greeson <br />JACOB-4 OP ID: RF <br />09/30/2020 <br />Ruth Friddle <br />Southeastern Agency Group,Inc. <br />1501 Highwoods Blvd., St # 402 <br />Greensboro, NC 27410 <br />Scott Greeson <br />336-232-0218 336-218-7487 <br />rfriddle@sagnc.com <br />Bridgefield Casualty <br />Pennsylvania National <br />Jacobs Construction and <br />Development LLC <br />8102 Sommerwell St. <br />Raleigh, NC 27613 <br />Westchester Surplus Lines <br />B X 1,000,000 <br />X CL90747842 06/27/2020 06/27/2021 100,000 <br />X 5,000 <br />1,000,000 <br />2,000,000 <br />X 2,000,000 <br />1,000,000B <br />X AU90747842 06/27/2020 06/27/2021 <br />X 5,000,000 <br />X <br />B <br />UL90747842 06/27/2020 06/27/2021 <br />XA <br />0196-46394 06/05/2020 06/05/2021 1,000,000 <br />Y 1,000,000 <br />1,000,000 <br />C G71149572002 06/27/2020 06/27/2021 occ/aggr 2,000,000 <br />B Inland Marine CL90747842 06/27/2020 06/27/2021 rent/leas 200,000 <br />csandt@orangecountync.gov <br /> <br />Orange County is included as Additional Insured for General Liability as <br />required by written and signed contract. Umbrella follows form. <br />ORANGEC <br />Orange County <br />Planning & Inspections Dept <br />P.O. Box 8181 <br />Hillsborough, NC 27278 <br />336-232-0218 <br />10335 <br />14990 <br />Owner/Cont Prot. <br />Pollution Liabilit <br />DocuSign Envelope ID: A5BEDB12-D1EE-4373-9B76-3CFD052251E3