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ACORD" CERTIFICATE OF LIABILITY INSURANCEu" n(wirer u kb.....---- I 04/07/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Carleen Goforth UWHARRIE INSURANCE AGENCY,LLC PH Nq l (704)463-0216 FAX�� (704)463-0218 PO BOX 543 E-MAIL forth@uwharrieinsurance.com ADDRES§ —----- --— —.�-- — t INSURERS)AFFORDING COVERAGE ! NAIC R RICHFIELD NC 28137-0543 INSURER A: NATIONAL FIRE&MARINE INSURANCE COMPANY } 20079 INSURED INSURER B: .___ _ ..._.._ • M&M Fireworks LLC INSURER C: -1-- 46775 Mook Mock Dr INSURER : INSURER E: New London NC 28127-8591 INSURER F: • COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR' TYPE OF INSURANCE ,ADD POLICY EFF POLICY EXPI LIMITS LTR I INSD I INVD WVQ POLICY NUMBER (MMIDDFYYYY) (MM!DDIYYYY1 X' COMMERCIAL GENERAL LIABILITY I I EACH OCCURRENCEI S 1,000,000l DAMAGE TO RENTED —_+-- --- CLAIMS-MADE X f OCCUR t PREMISES(En occurrence) S 5 100 000000 — — " MED EXP(Any one person) $ �_-- ---------- A x 172LPS037922 07/25/2020 07/25/2021 1 PERSONAL a ADV INJURY S 1,000.000 GEMLAGGREGA_TE LIMIT APPLIES PER. GENERAL AGGREGATE 1$ 2,000,000 Xlr PRO- i { INC WITHIN POLICY( 1 JECT (, 1 LOC PRODUCTS AGG I S OTHER: I} '1,000 DEDUCTIBLE S GEN AGG LIMIT AUTOMOBILE LIABILITYi I COMBINED SINGLE LIMIT $ (Eaaccidenl)-- -----. ._._---------- -----1 ANY AUTOI I j BODILY INJURY(Per person) S i ..�OWNED 'SCHEDULED I AUTOS ONLY AUTOS BODILY INJURY(Per arxidenl) S HIRED NON-OWNEDPROPERTY.-- -- - G I � I DAMAGE s AUTOS ONLY AUTOS ONLY i _(Peraccident) 1 _-_1 UMBRELLALIAB ,OCCUR i I EACH OCCURRENCE_ s EXCESS LIAR 1 CLAIMS-MADE' 1,AGGREGATE $ DEC) 1 f RETENTIONS 1 I S WORKERS COMPENSATION i J +PER "O•IH- AND EMPLOYERS'LIABILITY YIN _i STATUTEi_ i ER ANIPROPRIETORIPARTNER/EXECUTIVE i E.L.EACH ACCIDENT S OFFICERJMEMBEREXCLUDED? N!A I------------ ---- _-.�____._.___—.._�—__ (Mandatory In NH) I El.DISEASE-EA EMPLOYEE;S If yes describe under DESCRIPTION OF OPERATIONS below ' E.L.DISEASE-POLICY LIMIT 1$ 1 i l i ,• DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) FIREWORK SHOWS;ADDITIONAL INSURED STATUS APPLIES WHEN REQUIRED BY A WRITTEN CONTRACT PER TERMS AND CONDITIONS ON FORM M-5350A Show Date:July 4,2021 CERTIFICATE HOLDER CANCELLATION Joel Ammons SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ammons Farm Land,LLC ACCORDANCE WITH THE POLICY PROVISIONS. 1973 Farrell Road Sanford,NC 27330 AUTHORIZED REPRESENTATIVE Carleen Goforth ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD