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ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? <br />INSR ADDL SUBR <br />LTR INSD WVD <br />DATE (MM/DD/YYYY) <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 <br />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 RENTED <br />CLAIMS-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 AGG $JECT <br />OTHER:$ <br />COMBINED SINGLE LIMIT $(Ea accident) <br />ANY AUTO BODILY INJURY (Per person)$ <br />OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS <br />HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) <br />$ <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 LIMIT $DESCRIPTION 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. <br />The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) <br />CERTIFICATE OF LIABILITY INSURANCE <br />Lockton Insurance Brokers, LLC <br />CA License #OF15767 <br />Three Embarcadero Center, Suite 600 <br />San Francisco CA 94111 <br />(415) 568-4000 <br />Granicus, LLC <br />Granicus, Inc <br />408 Saint Peter Street <br />Suite 600 <br />Saint Paul MN 55102 <br />GRAIN01 <br />The Continental Insurance Company 35289 <br />National Fire Insurance Co of Hartford 20478 <br />Valley Forge Insurance Company 20508 <br />X <br />X <br />1,000,000 <br />1,000,000 <br />15,000 <br />1,000,000 <br />2,000,000 <br />2,000,000 <br />X X <br />X Comp $100 DedX Coll $1,000 Ded <br />1,000,000 <br />XXXXXXX <br />XXXXXXX <br />XXXXXXX <br />XXXXXXX <br />XXXXXXX <br />XXXXXXX <br />XXXXXXX <br />N <br />X <br />1,000,000 <br />1,000,000 <br />1,000,000 <br />B 6043664084 10/20/2019 10/20/2020 <br />A 6043664103 10/20/2019 10/20/2020 <br />C 6043364067 (AOS)10/20/2019 10/20/2020 <br />C 6043364070 (CA)10/20/2019 10/20/2020 <br />NOT APPLICABLE <br />10/20/2020 <br />1418581 <br />N N <br />N N <br />N <br />6/8/2020 <br />15579487 <br />15579487 XXXXXXX <br />Orange County Government <br />Attn: Risk Management <br />PO Box 8181 <br />Hillsborough NC 27278 <br />THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S) REFERENCED. <br />Evidence of Insurance <br />X X <br />See Attachment <br />DocuSign Envelope ID: 0F92FF6F-9473-4C99-B35C-C4596054C8EC