2022-258-E-Planning-Wolverine Pump & Utility-Historic Rogers Road installation of OWASA sewer servive stub out for 7731 Rogers Rd

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DocuSign Envelope ID:632D2AA8-DECD-4F1 F-986C-1 FADA9BC39E2 WOLVE-1 '4��o° CERTIFICATE OF LIABILITY INSURANCE D11/09ATE /2021Y) 11/09/2021 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 endorsements. PRODUCER 336-232-0218 cA0M ffT Ruth Friddle Southeastern Agency Group,lnc. PHONE 336-232-0218 FAX 336-218-7487 1501 Highwoods Blvd.,St#402 A/c,No,Ext: A/C,No): Greensboro,INC 27410 E-UAIE ,rfriddle@Sagnc.com Greg Myers INSURERS AFFORDING COVERAGE NAIC# INSURER A:Liberty Mutual Insurance INSURED INSURER B:Nautilus Insurance Company Wolverine Pump&Utility LLC 117 West Union Street INSURERC: Hillsborough,INC 27278 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBE • 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 INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPNYYY LTR LIMITS B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE [X] OCCUR X NN1300457 08/07/2021 08/07/2022 DAMAGMISE TO RENTED 100,000 MED EXP(Any oneperson) 5,000 PERSONAL&ADVINJURY 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 POLICY JE� LOC PRODUCTS-COMP/OP AGG 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (EaANY AUTO BODILY INJURY Per erson OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident AUT OS ONLY NON ONLY Per PER e DAMAGE UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION$ A WORKERS COMPENSATION X PER UT, I I OTH- AND EMPLOYERS'LIABILITY Y/N WC5-39S-744545-011 08/07/2021 08/07/2022 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It 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) i csandt@orangecountync.gov i Orange County is included as Additional Insured for General Liability as required by written and signed contract per form L815(attached). I i CERTIFICATE HOLDER CANCELLATION ORANGEC 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. Planning&Inspections Dept P.O. Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough,NC 27278 Greg Myers ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD