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DocuSign Envelope ID:BD69DF46-15CD-49E6-8588-93617FCCFB94 <br /> N O R T H ` C A R O L I N A <br /> ASSOCIATION OF COUNTY COMMISSIONERS <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 /> na|wigx.mocr$OV and is issued as a m*xev,in�rm�ion only. Tmsoe�i�oo�uomemn" <br /> rights upon the certificate holder other than those provided inthe <br /> MEMBER: <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 /> *ao Hillsboro Street,Suite 110 <br /> Pittsboro,NC 27312 <br /> COVERAGES <br /> Type of Coverage Coverage Effective Expiration <br /> Contract# Date Date Limits <br /> Coverage A: <br /> WORKERS'COMPENSATION <br /> vvC'oH-*75-16 July 1.un1s July 1,2017 Statutory <br /> Coverage B: <br /> EMPLOYERS'LIABILITY <br /> . WC-CH-475-16 July 1.cn1w July 1.uo1r. $2,000,000 <br /> Coverage C: <br /> OTHER STATES <br /> vvC-CH'475'16 July 1.zo1n July 1.2o1r Statutory <br /> Additional Information: Evidence fo Coverage. <br /> CERTIFICATE HOLDER: Cancellation: Should any of the described coverage documents herein be cancelled before <br /> m*oxpinuivoda\euhown mewCACC Pools vwnendeavor m mail umxannuonotoma <br /> Orange County Dept o ' <br /> � Certificate Holder named herein,but failure m mail such notice shall impose noobligation <br /> Services or liability of any kind upon the NCACC Pools,its agents or representatives,or the issuer of <br /> P.O. Box 8181 this certificate. <br /> Hillsborough,moeruru <br /> By: Collin Klein, Underwriting | -~��� I Tvu»niuianmrtmamnAco | —� ' 7/12s016 <br /> Certificate MeiIed/E-Mailed or Faxed to: <br /> Orange County Dept. o Social <br /> Services <br /> P.O. Box 8181 <br /> Hillsborough, NC 27278 <br />