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DocuSign Envelope ID: 55869249-D071-43C6-B9B7-126B43EDD48D <br /> N C) R T H w CC A R 0 L I N A <br /> ASSOCIATION 01P COUN-1-Y COMMISSIONFRS <br /> WORKERS COMPENSATION COVERAGE CERTIFICATE <br /> COVERAGE PROVIDER: <br /> NCACC Liability and Property Pool <br /> 215 North Dawson Street This certificate is provided by the NCACC Workers'Compensation Pool <br /> Raleigh, NC 27603 and is issued as a matter of information only. This certificate confers no <br /> MEMBER: rights upon the certificate holder other than those provided in the <br /> coverage document. This certificate does not amend,extend,or alter the <br /> Chatham Transit Network coverage afforded by the coverage documents listed herein. <br /> P.O.Box 1032 <br /> Piftsboro,NC 27312 <br /> COVERAGES <br /> Type of Coverage Coverage Effective Expiration <br /> Contract# Date Date Limits <br /> Coverage A: <br /> WORKERS'COMPENSATION <br /> WC-CH-475-15 July 1,2015 July 1,2016 Statutory <br /> Coverage B: <br /> EMPLOYERS'LIABILITY <br /> WC-CH-475-15 July 1,2015 July 1,2016 $2,000,000 <br /> Coverage C: <br /> OTHER STATES <br /> WC-CH-475-15 July 1,2015 July 1,2016 Statutory <br /> Additional Information: Evidence of Coverage <br /> CERTIFICATE HOLDER: Cancellation: Should any of the described coverage documents herein be cancelled before <br /> Orange County Dept.of Social Services the expiration date shown, the NCACC Pools will endeavor to mail written notice to the <br /> Certificate Holder named herein,but failure to mail such notice shall impose no obligation <br /> PO Box 8181 or liability of any kind upon the NCACC Pools, its agents or representatives,or the issuer of <br /> Hillsborough,NC 27278 this certificate, <br /> By: Willie Allen, Underwriter <br /> for the NCACC 112712:0116 <br /> Certificate Malled/E-Mailed or Faxed to: <br /> Orange County Dept.of Social Services <br /> PO Box 8181 <br /> Hillsborough, NC 27278 <br />