2015-535-E Health - Piedmont Health Services, Inc. - 2015-16 Outside Agency Performance Agreement

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DocuSign Envelope ID: B8F76F11-8DOD-43D5-8654-06F0031808EC �-- , PIEDM17 OP ID: KB ACORC�"' CERTIFICATE OF LIABILITY INSURANCE DA07/13/201 Y) �►.--""' 07/13/2015 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 CONTACT Senn Dunn-Charlotte Kendra A. Biddle, CPCU, CIC 440 South Church St.,Ste 500 a/c"ro EXt:336-899-2410 FAX No): 336-841-5319 Charlotte,NC 28202 E-MAIL kbiddle @senndunn.com M.Bryan Beasley,CIC ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Massachusetts Bay Insurance Co INSURED Piedmont Health Services Inc. INSURERB:Hanover American Insurance Co 36064 Lydia Mason 299 Lloyd St. INSURERC:The Hanover Insurance Company 22292 Carrboro, NC 27510 INSURER D:Allmerica Financial Benefit INSURER E:Columbia Casualty Company 31127 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 DDL UBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 1XII OCCUR X ZZ6-A534491-00 02/01/2015 02/01/2016 DAMAGE TO RENTED 500 000 PREMISES Ea occurrence $ , MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000 POLICY JjECT [::] LOC PRODUCTS-COMP/OPAGG $ 3,000,000 OTHER I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident D X ANY AUTO X AW6A534528 02/01/2015 02/01/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LAB CLAIMS-MADE X UH6-A534495-00 02/01/2015 02/01/2016 AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/" W26A524525 02/01/2015 02/01/2016 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 E "Wrap Around" HMA4031897817 10/11/2014 10/11/2015 11000,000 Each Claim Professional Liab 3,000,000 Aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) If required by written contract the following is an Additional Insured with respect to General and Auto Liability Coverage: Orange County, NC CERTIFICATE HOLDER CANCELLATION ORAN818 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County ACCORDANCE WITH THE POLICY PROVISIONS. Risk Manager PO Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough, NC 27278 Qe , ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD