Orange County NC Website
Browse       Search
INSR ADDL SUBR <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 />Continental Western Insurance Company <br />9/22/2023 <br />USI Insurance Services, LLC <br />6100 Fairview Road, Suite 1400 <br />Charlotte, NC 28210 <br />Gema Rains <br />gema.rains@usi.com <br />GBA Construction, LLC <br />19109 West Catawba Avenue, Suite 110 <br />Cornelius, NC 28031 <br />44520 <br />10804 <br />A X <br />X <br />X BI/PD Dedt: $5,000 <br />X <br />X EPK139915 06/01/2023 06/01/2024 1,000,000 <br />50,000 <br />5,000 <br />1,000,000 <br />2,000,000 <br />2,000,000 <br />B <br />X <br />X X <br />X CNA440850844 06/01/2023 06/01/2024 1,000,000 <br />A <br />X X <br />X 0 <br />X EFX120451 06/01/2023 06/01/2024 5,000,000 <br />5,000,000 <br />A Pollution Liab.EPK139915 06/01/2023 06/01/2024 Limit: $1,000,000 <br />Orange County, its officers, official agents and employees are included as an Additional Insured with <br />respect to General Liability, Auto Liability and Umbrella Liability (follow-form) in accordance to the <br />policy terms and conditions. <br />Designate Orange County <br />Attn: Risk Management <br />P.O. Box 8181 <br />Hillsborough, NC 27278 <br />1 of 1 <br />#S41944325/M40481886 <br />GREENWAS2Client#: 1497902 <br />NXNE4 <br />1 of 1 <br />#S41944325/M40481886 <br />DocuSign Envelope ID: 94DEC07F-694B-4CD9-9162-F90B545FF524