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INSR ADDLSUBRLTRINSR WVD
<br />DATE (MM/DD/YYYY)
<br />PRODUCER CONTACTNAME:
<br />FAXPHONE(A/C, No):(A/C, No, Ext):
<br />E-MAILADDRESS:
<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 />COMMERCIAL GENERAL LIABILITY
<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 />INSURER(S) AFFORDING COVERAGE NAIC #
<br />Y / N
<br />N / A
<br />(Mandatory in NH)
<br />ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?
<br />EACH OCCURRENCE $
<br />DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR
<br />MED EXP (Any one person) $
<br />PERSONAL & ADV INJURY $
<br />GENERAL AGGREGATE $
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP AGG $
<br />$
<br />PRO-
<br />OTHER:
<br />LOCJECT
<br />COMBINED SINGLE LIMIT $(Ea accident)
<br />BODILY INJURY (Per person) $ANY AUTO
<br />OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
<br />AUTOS ONLYHIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE $
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $
<br />$
<br />PER OTH-STATUTE ER
<br />E.L. EACH ACCIDENT $
<br />E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
<br />POLICY
<br />NON-OWNED
<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 any 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 />ACORDTM CERTIFICATE OF LIABILITY INSURANCE
<br />Hartford Casualty Insurance Company
<br />Twin City Fire Insurance Company
<br />Travelers Casualty & Surety Co of Amer
<br />2/26/2021
<br />McGriff Insurance Services
<br />5850 Waterloo Road, Suite 240
<br />Columbia, MD 21045
<br />410 480-4400
<br />Julie O'Connor
<br />410 480-4411 866-548-4197
<br />joconnor@mcgriffinsurance.com
<br />Facility Dynamics Engineering Corp
<br />6760 Alexander Bell Drive
<br />Suite 200
<br />Columbia, MD 21046
<br />29424
<br />29459
<br />31194
<br />AX
<br />X
<br />XX
<br />30SBAVJ3418 09/01/2020 09/01/2021 1,000,000
<br />300,000
<br />10,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />A
<br />XX
<br />30SBAVJ3418 09/01/2020 09/01/2021 1,000,000
<br />A XX
<br />X 10000
<br />30SBAVJ3418 09/01/2020 09/01/2021 5,000,000
<br />5,000,000
<br />B
<br />N
<br />30WBCCN7804 09/01/2020 09/01/2021
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />C Professional Liab
<br />Claims Made
<br />106880962 03/02/2021 03/02/2022 3,000,000 / Claim
<br />5,000,000 Aggregate
<br />200,000 SIR/Deductible
<br />RE: Insurance Verification
<br />Orange County, North Carolina
<br />PO Box 8181
<br />Hillsborough, NC 27278
<br />1 of 1#S27437185/M27436800
<br />140FACILDYNClient#: 1594858
<br />MEBAT1 of 1#S27437185/M27436800
<br />DocuSign Envelope ID: 12BDD0F0-7FBF-43B6-BACD-F124F87E24FA
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