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DocuSign Envelope ID: 9BE92A26-4CEE-4AC3-BC41-BB345E3551A4 <br /> ACGR©® DATE(MMIDDIYYYY) <br /> CERTIFICATE OF LIABILITY INSURANCE 6/302016 <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 Carla Dubuc <br /> _NAME: <br /> Sanford Insurance Center [AHC No,Exq: (919)775-7216 jalc,No): (888)280-1697m <br /> 1722 S HORNER BLVD EMAIL <br /> ADDRESS: <br /> INSURERS AFFORDING COVERAGE Y NAIC II <br /> SANFORD NC 27330 INSuRERA:Stonewood Insurance Company <br /> INSURED INSURER B <br /> Personalized Patients Home Assistance, DBA: Dorothea INSURER C: <br /> 109 Concord Dr INSURER D: <br /> INSURER E.... _�... _.e._.._ � ......Y.,....,...._...__ <br /> Chapel Hill NC 27516 INSURER F: <br /> COVERAGES CERTIFICATE NUMBER:CL1663003949 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 /> INSR TYPE OF INSURANCE ADOL SUER POLICY EFF POLICY EXP <br /> rJNSD WVD POLICY NUMBER IMM/DD/YYYY) (MMIDD/YYYY) UMITS <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> DAMAGE TO RENTED <br /> CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ <br /> „,„•„„„__ MED EXP(Any one person) $ <br /> PERSONAL&ADV INJURY $ <br /> GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY PRO- <br /> JECT LOC PRODUCTS-COMPIOP AGG $ mm <br /> OTHER: _...n._._$ _._....,_.. <br /> AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ <br /> _LEA accident <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS AUTOS <br /> NON-OWNED PROPERTY DAMAGE <br /> HIRED AUTOS AUTOS (Per accident) <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION PER 0TH- <br /> !AND EMPLOYERS'LIABILITY Y/N TATUTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE I M EL EACH ACCIDENT _i$ 100 000 <br /> A OFFICER/ME BER EXCLU©EO? ,,.,A TRA 7/1/2016 7/1/2017 <br /> (Mandatory EL.DISEASE-EA EMPLOYEE $ 100,000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ 500,000) <br /> I <br /> DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more�I a�e„I a required) <br /> r„ f1.I- �� r/ �' <br /> hANlc :(()IICV`uF.b,,. <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Orange County DSS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Hill sbor©ugh, NC 27278 <br /> AUTHORIZED REPRESENTATIVE <br /> S Insurance Ce/CARLA <br /> 01988.2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD <br /> INS025(201401) <br />