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DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487
<br /> KAHCA-1 OP ID:AC
<br /> AC©RQ DATE.(MMIDD/YYYY)
<br /> CERTIFICATE OF LIABILITY INSURANCE 07/1212016
<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
<br /> Agency,Inc. NAME: Tony McCroskey, CIC
<br /> Granite Insurance A
<br /> 9 y, PHONE FAX
<br /> 56 North Main Street s.alc,No.Exth 828-396-3342 lAJC,No):828 496-3834
<br /> Post Office Drawer 620 E-MAIL
<br /> Granite Falls,NC 28630-0620 ADDRESS:tmccroskey@graniteinsurance.com
<br /> Tony McCroskey,CIC INSURER(S)AFFORDING COVERAGE NAIC tf
<br /> INSURER A:Manchester Specialty Programs
<br /> INSURED KAH Care, LLC .._._._.....-INSURER E.....
<br /> INSURER ....... ..
<br /> DBA Right at Home suRE B Synergy Insurance Company 12773
<br /> 4905 Pine Cone Drive, Suite 2 INSURER C:
<br /> Durham, NC 27707 INSURER D
<br /> INSURER E
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 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 ADDL sunk- POLICY EFF POLICY EXP
<br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000
<br /> AMAGIEf ID RENTED
<br /> CLAIMS-MADE ', OCCUR MAC502518200 02/1612016 02116/2017 PREMISESgEaoccurrence; S 100,000
<br /> MED EXP(Any one person) S 5,000
<br /> PERSONAL&ADV INJURY s 1,000,000
<br /> GE 'L AGGREGATE LIMIT APPLIES PER 1 GENERAL AGGREGATE S 3,000,000
<br /> PRO-
<br /> POLICY 1 JECT I LOC I PRODUCTS-COMP/OP AGG S 3,000,000
<br /> '...OTHER.,
<br /> AUTOMOBILE LIABILITY ,. COMBINED SINGLE LIMIT S 1,000,000
<br /> Ea accidence
<br /> A ANY AUTO MAC502518200 02/16/2016 02/16/2017 BODILY INJURY(Per person) S
<br /> _ ALL OWNED .._._....... SCHEDULED _.. -. .......... .. -...._. .. .. ...._,
<br /> AUTOS NON-OWNED__ AUTOS BODILY INJUURY(Per aocident) 5
<br /> PROPERTYDAMAGE S
<br /> UTOS (Per accident)
<br /> X
<br /> HIRED AUTOS X AUTOS
<br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE S
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE S
<br /> DED I RETENTION S S
<br /> WORKERS COMPENSATION PER OTH-
<br /> AND EMPLOYERS'LIABILITY STATUTE ER -
<br /> B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA WC100-000481-116 05/05/2016 05/05/2017 E L EACH ACCIDENT s 1,000,000
<br /> OFFICER/MEMBER EXCLUDED? --""-" "----"--"--
<br /> (Mandatory inNH) EL,DISEASE-EA EMPLOYEE S 1,000,000
<br /> ff yes describe under
<br /> DESCRIPTION OF OPERATIONS below E ,DISEASE-POLICY LIMIT S 1,000,000
<br /> A Property Section MAC502518200 02/1612016 02/16/2017
<br /> A Theft MAC502518200 Client Pr 10,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> ORANG-1
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> Orange County Department of ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Social Services
<br /> PO Box 8181 AUTHORIZED REPRESENTATIVE
<br /> Hillsborough,NC 27278 /f
<br /> 1988-2014 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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