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DocuSign Envelope ID: 51 CB0066-1185-4FDA-AC7B-8C1 F27F6013F
<br /> ____,.......4p CHARL-1 OP ID: MR
<br /> ACC3R0" CERTIFICATE OF LIABILITY INSURANCE DATE(MMroDrcYYYI
<br /> ` / 08/11/2016
<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 NAMEACT Margo G. Roberts,AAI,CISR
<br /> Summers Thompson Lowry,Inc. PHONE FAX
<br /> 100 Europa Drive,Suite 571 (A/C,No,_Extl 919-969-5300 (A!c Nol 919.942-4221
<br /> Chapel Hill,NC 27517 E-MAIL
<br /> p ADDRESS:margoestlinsure.com
<br /> C.Duke Thompson CPCU ARM
<br /> INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURER A:Philadelphia Ins Co
<br /> INSURED Charles House Association INSURER B:*ISurity
<br /> Paul Klever
<br /> 751 Sunrise Road INSURER C;
<br /> Chapel Hill, NC 27514 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 VNTH 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 /> IR TYPE OF INSURANCE_ ADDL StiHR POLICY NUMBER POUCY (MM!D
<br /> LTR D!YYYY) LIMITS
<br /> LT INSD WVD
<br /> A X COMMERCIAL GENERAL LIABILITY '. EACH OCCURRENCE '..$ 1,000,000
<br /> DAMAGE"T2J R-ELATED �
<br /> X PHPK1466031 05/10/2016 05/10/2017 100,000
<br /> CLAIMS-MADE OCCUR PREMISES(EaoccurrenceJ..._.,-,. $
<br /> MED EXIP(Any one person) $ 5,000
<br /> '..
<br /> PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN"L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000..
<br /> POLICY PRO JECT LOC PRODUCTS-COMP/OPAGG $ 3,000 000
<br /> OTHER Emp Ben. $ 1,000,000
<br /> AUTOMOBILE LIABILITY $ 1,000,000'.
<br /> COMBINED SONGLE LIMIT
<br /> (Ea accidentj__
<br /> A ANY AUTO PHPK1466031 05/10/2016 05/10/2017 BODILY(INJURY(Per person) $
<br /> ALL OWNED --_..__.. SCHEDULED -. _,_-_,......_._.- _ . .....__._....
<br /> AUTOS AUTOS BODILY INJURY Y(Per cderi)r $
<br /> .... NON-OWNED PROPERTY DAMAGE $
<br /> X X
<br /> HIRED AUTOS AUTOS (Per accHent)..._
<br /> X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
<br /> A EXCESS LIAB CLAIMS-MADE PHUB533292 05/10/2016 05/10/2017 AGGREGATE 1 $ 1,000,000
<br /> ....... ....
<br /> l RETENTION$ 10000 __._...... .... . ._,.. s
<br /> DED I X I
<br /> WORKERS COMPENSATION X PER 0TH-
<br /> AND EMPLOYERS'LIABILITY STATUTE ER
<br /> B ANY PROPRIETORPARTNER/EXECUTIVE !N
<br /> ` I N r a WC19056-2015 06/25/2016 06/25/2017 EL EACH ACCIDENT S 500,000
<br /> OFFICER/VEMBER EXCLUDED? — - ---
<br /> (Mandatory in NH) E L DISEASE EA EMPLOYEE S 500,000
<br /> If yes,describe under
<br /> DESORPTION OF OPERATIONS below E L DISEASE•POLICY LVMVT S 500,000
<br /> A Molestation/Sexual PHPK1466031 05/10/2016 05/10/2017 Agg 1,000,000
<br /> Misconduct Occ 1,000,000
<br /> DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES (ACORD 101,Addttlonal Remarks Schedule,may be attached If more space Is required)
<br /> For Information Purposes
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> ORANGSS
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> Orange County Social Services ACCORDANCE WITH THE POLICY PROVISIONS,
<br /> Adult Services -
<br /> PO Box 8181 AUTHORIZED REPRESENTATIVE
<br /> Hillsborough, NC 27278 C 21,4-3,446--,
<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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