VM_NEW VENDOR PRACTICE ORDER

Case Number: 000-000028

Property Address: 123 Main Street, Anytown, NC 00000
Date Completed: 09/18/2019

Signature: Date: 09/18/2019

VM_NEW VENDOR PRACTICE ORDER Completed on 09/18/2019 Page 1 of 4

Case Number: 000-000028 123 Main Street, Anytown, NC 00000

1. Corey License

VM_NEW VENDOR PRACTICE ORDER Completed on 09/18/2019 Page 2 of 4

Case Number: 000-000028 123 Main Street, Anytown, NC 00000

VM_NEW VENDOR PRACTICE ORDER Completed on 09/18/2019 Page 3 of 4

Case Number: 000-000028 123 Main Street, Anytown, NC 00000

DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 03/19/2019

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
NAME:
Next Insurance, Inc. PHONE (855) 222-5919 FAX
(A/C, No, Ext): (A/C, No):
PO Box 60787 E-MAIL
Palo Alto, CA 94306 ADDRESS: [email protected]
INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A : State National Insurance Company, Inc. 12831

INSURED INSURER B :
Corey Mobley
Coreys General Services, LLC INSURER C :
1130 Deep Hollow Ct INSURER D :
Waxhaw, NC 28173
INSURER E :

INSURER F :
COVERAGES CERTIFICATE NUMBER: 6727648 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 ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $ 100,000.00
MED EXP (Any one person) $ 15,000.00
A NXT4RWD27F-00-GL 03/19/2019 03/19/2020 PERSONAL & ADV INJURY $ 1,000,000.00

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000.00

X POLICY PRO-
JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000.00

OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $

DED RETENTION $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS' LIABILITY STATUTE ER
Y/N
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $

Each Occurrence: $25,000.00

A Contractors Errors and Omissions NXT4RWD27F-00-GL 03/19/2019 03/19/2020 Aggregate: $50,000.00

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

Proof of insurance

CERTIFICATE HOLDER CANCELLATION

Corey Mobley
Coreys General Services, LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
1130 Deep Hollow Ct THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Waxhaw, NC 28173 ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

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ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

VM_NEW VENDOR PRACTICE ORDER Completed on 09/18/2019 Page 4 of 4