CERTIFICATE OF LIABILITY INSURANCE
Review draft in certificate field order. The certificate is issued from your AMS after approval.
Date (MM/DD/YYYY)10/30/2026
ProducerTriangle Demo Agency
Durham, NC
(919) 555-0142
Insurers affording coverage
INSURER AAuto-Owners
INSURER BCincinnati Insurance
Insured
Riverside Roofing LLC
402 Old Oxford Rd
Durham, NC 27712
Certificate numberDRAFT-8860Revision number0
COVERAGES
| INSR LTR | TYPE OF INSURANCE | ADDL INSD | SUBR WVD | POLICY NUMBER | POLICY EFF | POLICY EXP | LIMITS |
|---|---|---|---|---|---|---|---|
| A | GENERAL LIABILITY | Y | N | GL-3903170 | 05/19/2026 | 05/19/2027 | Each occurrence$1,000,000 Damage to rented premises$100,000 Med exp (any one person)$5,000 Personal and adv injury$1,000,000 |
| A | COMMERCIAL AUTO | Y | N | CA-4126066 | 05/19/2026 | 05/19/2027 | Combined single limit (ea accident)$1,000,000 |
| B | WORKERS' COMP | N/A | N | WC-7024747 | 05/19/2026 | 05/19/2027 | E.L. each accident$1,000,000 E.L. disease, each employee$1,000,000 E.L. disease, policy limit$1,000,000 |
| A | UMBRELLA | Y | N | UM-9840171 | 05/19/2026 | 05/19/2027 | Each occurrence$2,000,000 Aggregate$2,000,000 |
Description of operations / locations / vehicles
Certificate holder is included as Additional Insured where required by written contract for the Glenwood Ave job, subject to policy terms, conditions and exclusions.
General liability GL-3903170: Additional insured (CG 20 10).
Commercial auto CA-4126066: Designated insured for covered autos liability (CA 20 48).
Umbrella UM-9840171: Follow form (UMB FF).
Certificate holder
Atlas Construction Group
1 Glenwood Ave, Suite 600
Raleigh, NC 27603
CancellationShould any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions.Authorized representativeSigned on approval