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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 Companies <br />444 W. 47th Street, Suite 900 <br />Kansas City MO 64112-1906 <br />(816) 960-9000 <br />kcasu@lockton.com <br />PAYIT, LLC <br />1100 MAIN ST, SUITE 700 <br />KANSAS CITY MO 64105 <br />Sentinel Insurance Company, Ltd.11000 <br />The Hartford Business Service Center <br />X <br />X <br />1,000,000 <br />1,000,000 <br />10,000 <br />1,000,000 <br />2,000,000 <br />2,000,000 <br />X X <br />1,000,000 <br />XXXXXXX <br />XXXXXXX <br />XXXXXXX <br />XXXXXXX <br />X 6,000,000 <br />6,000,000 <br />XXXXXXX <br />Y <br />X <br />1,000,000 <br />1,000,000 <br />1,000,000 <br />A 37SBARH6901 3/1/2023 3/1/2024 <br />A 37SBARH6901 3/1/2023 3/1/2024 <br />A 37SBARH6901 3/1/2023 3/1/2024 <br />B 37WBCCD2936 3/1/2023 3/1/2024 <br />3/1/2024 <br />1410452 <br />Y N <br />N N <br />N N <br />N <br />7/17/2023 <br />19744056 <br />19744056 XXXXXXX <br />ORANGE COUNTY, NC <br />ORANGE COUNTY P.O. BOX 8181 <br />HILLSBOROUGH NC 27276 <br />ORANGE COUNTY, NC IS ADDITIONAL INSURED ON GENERAL LIABILITY COVERAGE, AS REQUIRED BY WRITTEN CONTRACT AND SUBJECT TO THE <br />TERMS AND CONDITIONS OF THE POLICY. <br />X <br />DocuSign Envelope ID: 66079055-D43F-47F3-9098-8F90C614308F