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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, LLC
<br />444 W. 47th St., Ste. 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 />The Continental Insurance Company 35289
<br />Hartford Casualty Insurance Company 29424
<br />Sentinel Insurance Company, Ltd.11000
<br />Valley Forge Insurance Company 20508
<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 />B 8018384901 3/1/2025 3/1/2026
<br />A 8018384929 3/1/2025 3/1/2026
<br />D 8018384915 3/1/2025 3/1/2026
<br />C 8018384896 3/1/2025 3/1/2026
<br />3/1/2026
<br />1410452
<br />Y N
<br />N N
<br />N N
<br />N
<br />2/28/2025
<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: AFBEB331-9B33-4564-AD1E-2C094745E539
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