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INSR ADDLSUBR
<br />LTR INSR 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 />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/EXECUTIVE
<br />OFFICER/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 $GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP AGG $
<br />$
<br />PRO-
<br />OTHER:
<br />LOCJECT
<br />COMBINED SINGLE LIMIT
<br />$(Ea accident)
<br />BODILY INJURY (Per person) $ANY AUTO
<br />OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
<br />AUTOS ONLY
<br />HIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident)
<br />$
<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 />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 />Crum & Forster Specialty Insurance Co.
<br />Century Surety Company
<br />Continental Western Insurance Company
<br />Key Risk Insurance Company
<br />8/12/2022
<br />USI Insurance Services, LLC
<br />6100 Fairview Road, Suite 1400
<br />Charlotte, NC 28210
<br />April Walker
<br />april.walker@usi.com
<br />GBA Construction, LLC
<br />19109 West Catawba Avenue, Suite 110
<br />Cornelius, NC 28031
<br />44520
<br />36951
<br />10804
<br />10885
<br />A X
<br />X
<br />X BI/PD Dedt: $5,000
<br />X
<br />EPK139915 05/28/2022 06/01/2023 1,000,000
<br />100,000
<br />5,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />C
<br />X
<br />X X
<br />CNA4408508 06/01/2022 06/01/2023 1,000,000
<br />B
<br />X X
<br />X 0
<br />EFX120451 05/28/2022 06/01/2023 5,000,000
<br />5,000,000
<br />D
<br />Y
<br />KEY0138142 06/01/2022 06/01/2023 X
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />A Pollution Liab. EPK139915 05/28/2022 06/01/2023 Limit: $1,000,000
<br />Orange County
<br />P.O. Box
<br />Hillsborough, NC 27278
<br />1 of 1
<br />#S37023265/M36170434
<br />GREENWAS2Client#: 1497902
<br />NXNE4
<br />1 of 1
<br />#S37023265/M36170434
<br />X
<br />X
<br />X
<br />Orange County is included as an Additional Insured with respect to General Liability, and Auto Liability as required by
<br />written contract in accordance to the policy terms and conditions. Umbrella Liability is follow-form over the General, Auto
<br />Liability and Workers Compensation coverages.
<br />DocuSign Envelope ID: F190BB1B-21DA-4BF3-9BE7-346D28FFD1E5
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