2016-396-E Health - Freedom House to provide Zone 4 Navigator Services

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DocuSign Envelope ID: F6D4D28D-1E29-4905-AB38-673A41BB7F34 A�T IJ DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/24/2016 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 Ellen Walker NAME: Business Insurers of Carolinas PHONE/ E, (919)968-4611 FAX Nn): (919)968-8991 800 Eastowne Drive, Suite 208 ADDREss:ewalker @business-insurers.com PO Box 2536 INSURER(S)AFFORDING COVERAGE NAIC# Chapel Hill NC 27515-2536 _INSURER A:Riverport 36684 INSURED INSURERB:United Wisconsin Insurance Company 29157 Freedom House Recovery Center, Inc INSURERC: 104 New Stateside Drive INSURERD: INSURER E: Chapel hill NC 27516 INSURER F: COVERAGES CERTIFICATE NUMBER:16/17 Revised 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 ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ X Professional Liability X CPA427860742 7/1/2016 7/1/2017 MED EXP(Any one person) $ 20,000 X Sexual & Physical Abuse PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OPAGG $ 3,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS X CPA427860742 7/1/2016 7/1/2017 BODILYINJURY(Peraccident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) $ Medical payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ CPA427860742 7/1/2016 7/1/2017 $ WORKERS COMPENSATION x 1 PEATUTE 1 ...1 EOTH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Y N/A B (Mandatory in NH) 2000013343 5/16/2016 5/16/2017 E L D I S E A S E E A E M P L O Y E E $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ 500,000 A Employee Dishonesty CPA427860742 7/1/2016 7/1/2017 25,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Orange County is also an additional insured with respect to General Liability and Automobile Liability, required by written contract. Forms attached. CERTIFICATE HOLDER CANCELLATION achambers @orangecountync.g SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Ellen Walker/ELLEN � 7..r_, ��!. �z ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)