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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B
<br /> 9Q� 1� I ALLIANCE OF
<br /> ❑(' NONPROFITS FOR ALLIANCE OF NONPROFITS FOR INSURANCE
<br /> INSURANCE RISK RETENTION GROUP(ANI)
<br /> www.insurancefornonprofits.org
<br /> A Head for Insurance.A Heart for Nonprofits.
<br /> COMMERCIAL LINES COMMON POLICY DECLARATIONS
<br /> PRODUCER: POLICY NUMBER: 2015-37160
<br /> BB&T Insurance Services, Inc.
<br /> P.O. Box 168 RENEWAL OF NUMBER: 2014-37160
<br /> Winston Salem, NC 27102
<br /> NAME OF INSURED AND MAILING ADDRESS:
<br /> North Carolina Public Health Foundation
<br /> P.O. Box 18763
<br /> Raleigh, NC 27619
<br /> POLICY PERIOD: FROM 07/19/2015 TO 07/19/2016
<br /> AT 12:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE
<br /> BUSINESS DESCRIPTION: Public health program
<br /> IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS
<br /> POLICY, WE AGREE WITH YOU TO PROVIDE THE COVERAGE AS STATED IN THIS POLICY.
<br /> THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.THESE PREMIUMS MAY BE SUBJECT TO ADJUSTMENT.
<br /> PREMIUM
<br /> COMMERCIAL GENERAL LIABILITY COVERAGE PART - OCCURRENCE $844
<br /> COMMERCIAL AUTO LIABILITY COVERAGE PART Not Covered
<br /> IMPROPER SEXUAL CONDUCT COVERAGE PART Not Covered
<br /> COMMERCIAL LIQUOR LIABILITY COVERAGE PART INCLUDED
<br /> TERRORISM COVERAGE (Certified Acts) $4
<br /> TOTAL: $848
<br /> FORM(S)AND ENDORSEMENT(S)MADE A PART OF THIS POLICY AT TIME OF ISSUE:*
<br /> ANI-RRG-E03 01 13, ANI-RRG-E11 07 92, ANI-RRG-E12 05 92, ANI-RRG-E15 02 09, ANI-RRG-E22 08 95, ANI-RRG-E25 01 98, ANI-RRG-E28 01 99,
<br /> ANI-RRG-E29 12 09, ANI-RRG-E33 01 02, ANI-RRG-E42 07 06, ANI-RRG-E52 07 13, ANI-RRG-E60 07 12, ANI-RRG-E61 02 13, ANI-RRG-E7 10 04,
<br /> ANI-RRG-E70 07 13, ANI-RRG-E74 03 14, ANI-RRG-GL 04 01, ANI-RRG-LL 04 01, ANI-RRG-X1 02 15, CG 00 01 07 98, CG 00 33 01 96,
<br /> CG 20 10 07 04, CG 20 11 01 96, CG 20 12 07 98, CG 20 18 11 85, CG 20 20 11 85, CG 20 21 07 98, CG 20 26 07 04,
<br /> CG 20 34 07 04, CG 20 37 07 04, CG 21 16 07 98, CG 21 70 01 15, CG 22 44 1 1 85, CG 24 07 1 1 85, CG 25 04 11 85,
<br /> CG 77 94 04 93, IL 00 17 11 98, IL 02 69 09 00, IL 09 99 01 15, NPO-001 04 09, SCHEDULE G 01 80, SCHEDULE L 01 80,
<br /> *Omits applicable forms and endorsement if shown in specific coverage part/coverage form declarations.
<br /> These declarations and the common policy declarations,if applicable,together with the common policy conditions,coverage form(s)and forms
<br /> and endorsements,if any,issued to form a part thereof,complete the above numbered policy.
<br /> "NOTICE
<br /> This policy is issued by your risk retention group.Your risk
<br /> retention group may not be subject to all of the insurance laws BY
<br /> and regulations of your State.State insurance insolvency (AUTHORIZED REPRESENTATIVE)
<br /> guaranty funds are not available for your risk retention group." 07/16/2015
<br /> ANI -RRG -CO (02651-DB)
<br />
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