2014-396 DSS - Senior Care of Orange County, Inc. to provide Adult Day Health Services to DSS Clients $20,000

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Client#:955852 04SENIOCARI DTE(MMI DD/ _ ACORDTM CERTIFICATE OF LIABILITY INSURANCE 1 07/25/20114 4 07/25 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 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 C ACT NAME: BB&T Insurance Services,Inc. PHONE ggg 743-2217 8888279861 A1C No,Ext: (AtC,No): 414 Gallimore Dairy Road E-MAIL ADDRESS: Suite F INSURER(S)AFFORDING COVERAGE NAIC# Greensboro,NC 27409 INSURER A:Evanston Insurance Company 35378 INSURED INSURER B:Riverport Insurance Company 36684 Senior Care of Orange County INSURER C:Travelers Casualty&Surety Co 31194 Attn Day Health Cent INSURER D PO Box 8181 INSURER E: Hillsborough,NC 27278-8181 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 CONTRACTOR 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. LT TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A GENERAL LIABILITY SM901844 7/13/2014 07/13/2015 EA_CH OCCURRENCE $1,000,000 _ X COMMERCIAL GENERAL LIABILITY pq,y{AGE TO RENTED PREMISES Ea occurrence $50,000 X CLAIMS-MADE 1:1 OCCUR MED EXP(Any one person) $5,000 X BI/PD Ded:5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL SCHEDULED BODILY INJURY(Per accident $ AUTOS S P AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WG329001526503 2/0812014 p21p8J2p1 X WC STATU- OTH- AND EMPLOYERS'LIABILITY ...... .._ ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? I NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under ---- - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 A Errors&Omission SM901844 7/13/2014 07113/201 $1,000,000/$3,000,000 C Crime 105613156 5/15/2013 05/151201 $100,000 Ded:$1,000 1 1 1 r — —1 DESCRIPTION OF OPERATIONS/LOCATIONS t VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Miscellaneous Coverage-Professional Liability-Pol.#SM901844 Professional Liability Limit#1:1,000,000 Ded.#1:$5,000.00 Limit#2: 3,000,000 (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Senior Care of Orange County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn:Day Health Center ACCORDANCE WITH THE POLICY PROVISIONS. For Information Only PO Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough,NC 27278-8181 O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD #S12735871/M12735867 JUSC