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ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?
<br />INSR ADDL SUBRLTRINSD WVD
<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 />AUTOMOBILE LIABILITY
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />WORKERS COMPENSATIONAND 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 $(Ea accident)
<br />ANY AUTO BODILY INJURY (Per person) $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-STATUTE ER
<br />E.L. EACH ACCIDENT
<br />E.L. DISEASE - EA EMPLOYEE $If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />COMMERCIAL GENERAL LIABILITY
<br />Y / N
<br />N / A(Mandatory in NH)
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement onthis certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
<br />CERTIFICATE HOLDER CANCELLATION
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)
<br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
<br />$
<br />$
<br />$
<br />$
<br />$
<br />The ACORD name and logo are registered marks of ACORD
<br />7/6/2020
<br />(919) 469-2473 (919) 467-4987
<br />25666
<br />Alpha and Omega Group PC
<br />Ted Bartelt4601 Lake Boone Trail Ste 3C
<br />Raleigh, NC 27607
<br />25674
<br />31194
<br />A 1,000,000
<br />X 680IJ04070A20 5/19/2020 5/19/2021 1,000,000
<br />5,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />1,000,000B
<br />BA4F99976620 5/19/2020 5/19/2021
<br />5,000,000B
<br />CUP4F99980920 5/19/2020 5/19/2021 5,000,000
<br />10,000
<br />A
<br />X UB9K60615820 5/19/2020 5/19/2021 1,000,000N1,000,000
<br />1,000,000
<br />C Professional Liab 106741445R3 5/19/2020 Limit 1,000,000
<br />C Professional Liab 106741445R3 5/19/2020 5/19/2021 Aggregate 2,000,000
<br />Operations of the Named Insured covered by the above referenced policies.
<br />Orange County, its officers, official agents and employees are included as additional insureds with respects to General Liability if required by written contract.
<br /> A waiver of subrogation applies in favor of Orange County, its officers, official agents and employees with respects to Workers Compensation if required by
<br />written contract.
<br />Orange CountyAttn: Christopher Sandt, Planning & Inspections Dept.
<br />csandt@orangecountync.gov
<br />PO Box 8181
<br />Hillsborough, NC 27278
<br />ALPHAND-01 LHAMLET
<br />Trisure, an Alera Group Company4325 Lake Boone Trail, Suite 200Raleigh, NC 27607
<br />Lori F. Hamlet
<br />lhamlet@trisure.com
<br />Travelers Indemity Company of America (The)
<br />Travelers Property Casualty Company of America
<br />Travelers Casualty and Surety Company of America
<br />X
<br />5/19/2021
<br />X
<br />X
<br />X
<br />X
<br />X
<br />X
<br />X
<br />DocuSign Envelope ID: F08C6043-A165-4B95-9C6F-D2E8524A0B94
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