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PIEDM17 OP ID:KB <br /> CERTIFICATE OF LIABILITY INSURANCE DATE(M4/20 4 <br /> 1 011 412 0 1 4 <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 be endorsed. If SUBROGATION IS WAIVED,subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT Dick Dickens,CIC <br /> Senn Dunn-High Point FAX <br /> 2406 <br /> PHONE 336-899- <br /> 1400 Eastchester Drive,St 200 A/C No Ell: AIC No): <br /> High Point, as 27,CI E-MAIL ddickens@senndunn.com <br /> M.Bryan Beasley,CIC <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A:Selective Insurance Co of Amer 12572 <br /> INSURED Piedmont Health Services Inc. INSURER B:Selective Insurance Companies 12572 <br /> 299 Lloyd St. <br /> Carrboro,NC 27510 INSURER C: <br /> INSURER D: <br /> INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <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 /> ILTRR TYPE OF INSURANCE DL UBR POLICYNUMBER MM/DIpYEFF MMIDDNYY LIMITS <br /> GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 <br /> B X COMMERCIAL GENERAL LIABILITY 51971482 02/01/2014 0210112015 PREMISES Ea occurrence $ 100,00 <br /> CLAIMS-MADE EK OCCUR MED EXP(Any one person) $ 5,000 <br /> B X BusinessOwners S1971481 02/01/2014 02/0112015 PERSONAL BADVINJURY $ 1,000,00 <br /> GENERAL AGGREGATE $ 3,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,00 <br /> JECT <br /> POLICY PRO- L $ <br /> AUTOMOBILE LIABILITY (Ea <br /> accident) <br /> OMBI ED SINGLE LIMIT $ 1,000 000 <br /> B X ANY AUTO S1971482 02101/2014 02101/2015 BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY Per accident $ <br /> AUTOS AUTOS ( ) <br /> HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS PER ACCIDENT <br /> $ <br /> X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,00 <br /> B EXCESS LIAR CLAIMS-MADE 51971482 0210112014 02/01/2015 <br /> AGGREGATE $ 3,000,00 <br /> DED I X I RETENTION$ -0- $ <br /> WORKERS AND EMPLO ERS'L ABILIITY X TNRY LATT OE H <br /> A ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N WC 7977892 0210112014 02/0112015 E.L.EACH ACCIDENT $ 500,000 <br /> OFFICERIMEMBER EXCLUDED? ❑ NIA <br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 500,000 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> ORANGOV <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Orange County Government ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 200 S Cameron Street <br /> Hillsborough,NC 27278 AUTHORIZED REPRESENTATIVE-`. <br /> ©1988-2010 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD <br />