|
DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE
<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 be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />CONTACTPRODUCERNAME:
<br />FAXPHONE(A/C, No):(A/C, No, Ext):
<br />E-MAILADDRESS:
<br />PRODUCER
<br />CUSTOMER ID #:
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />INSURED INSURER A :
<br />INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<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 />ADDL SUBRINSR POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITSPOLICY NUMBERLTR (MM/DD/YYYY) (MM/DD/YYYY)INSR WVD
<br />GENERAL LIABILITY EACH OCCURRENCE $
<br />DAMAGE TO RENTEDCOMMERCIAL GENERAL LIABILITY $PREMISES (Ea occurrence)
<br />CLAIMS-MADE OCCUR MED EXP (Any one person) $
<br />PERSONAL & ADV INJURY $
<br />GENERAL AGGREGATE $
<br />GEN'L AGGREGATE LIMIT APPLIES PER:PRODUCTS - COMP/OP AGG $
<br />PRO-$POLICY LOCJECT
<br />COMBINED SINGLE LIMITAUTOMOBILE LIABILITY $(Ea accident)
<br />ANY AUTO BODILY INJURY (Per person) $
<br />ALL OWNED AUTOS BODILY INJURY (Per accident) $
<br />SCHEDULED AUTOS PROPERTY DAMAGE $(PER ACCIDENT)HIRED AUTOS
<br />$NON-OWNED AUTOS
<br />$
<br />UMBRELLA LIAB EACH OCCURRENCE $OCCUR
<br />EXCESS LIAB CLAIMS-MADE AGGREGATE $
<br />$DEDUCTIBLE
<br />$RETENTION $
<br />WC STATU- OTH-WORKERS COMPENSATION TORY LIMITS ERAND EMPLOYERS' LIABILITY Y / NANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $N / AOFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />CERTIFICATE HOLDER CANCELLATION
<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 />AUTHORIZED REPRESENTATIVE
<br />© 1988-2009 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORDACORD 25 (2009/09)
<br />OP ID: SR1
<br />12/18/2024
<br />Yates Insurance Services
<br />17014 New College Ave Ste 205
<br />Wildwood, MO 63040
<br />Edward E. Yates, Jr.DIMEN-1
<br />Dimensions in OH&S, Inc.
<br />David Machles, EdD, MPH
<br />9650 Strickland Rd S103-291
<br />Raleigh, NC 27615
<br />Hartford Insurance Company 22357
<br />RLI Insurance Company
<br />1,000,000
<br />AX X
<br />84SBATY0993 04/15/2024 04/15/2025 500,000
<br />X 10,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />X
<br />1,000,000
<br />AX 84SBATY0993 04/15/2024 04/15/2025
<br />AX 84SBATY0993 04/15/2024 04/15/2025
<br />XX 1,000,000
<br />A 84SBATY0993 04/15/2024 04/15/2025 CSL
<br />XX
<br />A 84WBCTD7229 04/15/2024 04/15/2025 500,000
<br />500,000
<br />500,000
<br />B Professional Liab RTP0041865 04/04/2024 04/04/2025 Aggregate 1,000,000
<br />Retention 2,500
<br />Orange County, NC, with whom you have agreed to perform work for by written contract, agreement or permit are additional insureds on the General Laibility shown.
<br />ORANGEC
<br />Orange County, NC
<br />131 W Margaret St 3rd Floor
<br />Hillsborough, NC 27278
<br />Docusign Envelope ID: 38AE4970-914D-4B09-95D3-50C868E177FF
|