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ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />INSR ADDL SUBR
<br />LTR INSD WVD
<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 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 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
<br />$(Ea accident)
<br />ANY AUTO BODILY INJURY (Per person)$
<br />OWNED SCHEDULED
<br />BODILY INJURY (Per accident)$AUTOS ONLY AUTOS
<br />HIRED NON-OWNED PROPERTY DAMAGE
<br />$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 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 />Joe Horton
<br />TERRA-2 OP ID: SS
<br />03/07/2024
<br />Sarabeth Spivey
<br />Southeastern Agency Group,Inc.
<br />1501 Highwoods Blvd., St # 402
<br />Greensboro, NC 27410
<br />Joe Horton
<br />336-232-0224 336-218-7487
<br />sbspivey@sagnc.com
<br />West Bend Mutual Insurance
<br />Axis Surplus Insurance Company
<br />Terraquest Environmental Consultants, PC
<br />100 E Ruffin St
<br />Mebane, NC 27302
<br />B X 1,000,000
<br />X X EMP21003173-03 09/09/2023 09/09/2024 100,000
<br />10,000
<br />1,000,000
<br />2,000,000
<br />X 2,000,000
<br />1,000,000A
<br />X B148027 09/09/2023 09/09/2024
<br />XX 1,000,000B
<br />EMX21000872-03 09/09/2023 09/09/2024 1,000,000
<br />XA
<br />B148059 09/09/2023 09/09/2024 1,000,000
<br />Y 1,000,000
<br />1,000,000
<br />B EMP21003173-03 09/09/2023 09/09/2024 Aggregate 2,000,000
<br />B Professional Liab EMP21003173-03 09/09/2023 09/09/2024 Aggregate 2,000,000
<br />chirni@orangecountync.gov
<br />Orange County, its officers, agents, & employees are named as Additional
<br />Insured on the General Liability as required by the written contract per
<br />form CG2010 (07 04) & CG2037 (07 04)
<br />ORANGEC
<br />Orange County
<br />PO Box 8181
<br />300 W Tryon St
<br />Hillsborough, NC 27278
<br />336-232-0224
<br />15350
<br />Pollution Liab
<br />Docusign Envelope ID: 9CFC9825-C1B2-4052-A1B7-EC9C576B5244
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