|
ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?
<br />INSR ADDL SUBRLTR INSD 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) $
<br />OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
<br />HIRED NON-OWNED
<br />PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY
<br />(Per accident)
<br />$
<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 $
<br />If yes, describe under
<br />E.L. DISEASE - POLICY LIMITDESCRIPTION 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.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 />12/14/2023
<br />License # 100101891
<br />(918) 551-7900
<br />20508
<br />TMA Holdings LLC
<br />1876 Utica Square
<br />Third Floor
<br />Tulsa, OK 74114
<br />20443
<br />35289
<br />14420
<br />A 1,000,000
<br />X B6074678759 9/22/2023 9/22/2024
<br />1,000,000
<br />10,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />EPL 10,000
<br />1,000,000A
<br />X B6074678759 9/22/2023 9/22/2024
<br />5,000,000B
<br />X B6074678762 9/22/2023 9/22/2024
<br />10,000 5,000,000
<br />C
<br />WC711555651 9/22/2023 9/22/2024 1,000,000
<br />1,000,000
<br />1,000,000
<br />D Professional Liabili DPS4003308 12/22/2023 Each Claim 4,000,000
<br />Orange County, its officers, agents and employees are to be designated as "additional insured" to the extent required by written agreement, signed by the
<br />insured, the Blanket Additional Insured endorsement applies to the Certificate Holder in reference to the General Liability, Auto Liability and Excess Liability
<br />as their interests may appear.
<br />Orange County
<br />300 West Tryon Street
<br />PO Box 8181
<br />Hillsborough, NC 27278
<br />TMAHOLD-01 CRAMEY
<br />Hub International Mid-America6100 S. Yale AvenueSuite 1900Tulsa, OK 74136
<br />Jasmine Watson
<br />jasmine.watson@hubinternational.com
<br />Valley Forge Insurance Company
<br />Continental Casualty Company
<br />The Continental Insurance Company
<br />Mount Vernon Specialty Insurance Company
<br />Aggregate
<br />X
<br />12/22/2024
<br />X
<br />X
<br />X
<br />X X
<br />X
<br />X
<br />DocuSign Envelope ID: 3E613CA5-0A37-4CD3-890F-47CC5E2F38B1
|