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DocuSign Envelope ID: F9379D59-22D8-4EF4-AC91-AAC7649616BA <br /> j - <br /> aritermr _41616se* <br /> ' wgrp, <br /> N 0 R T I-1 Nc:(:i." CAROLINA <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 /> Raleigh, NC 27603 and is issued as a matter of information only. This certificate confers no <br /> MEMBER: rights upon the certificate holder other than those provided in the <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 /> 480 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 /> WC-CH-475-16 July 1,2016 July 1,2017 Statutory <br /> — <br /> Coverage B: <br /> EMPLOYERS'LIABILITY <br /> WC-CH-475-16 July 1,2016_July 1,2017, $2000,000 <br /> Coverage C: <br /> OTHER STATES <br /> WC-CH-475-16 July 1,2016 July 1,2017 Statutory <br /> Additional Information: Evidence to Coverage. <br /> CERTIFICATE HOLDER: Cancellation: Should any of the described coverage documents herein be cancelled before <br /> the expiration date shown, the NCACC Pools will endeavor to mail written notice to the <br /> Orange County Dept.o Social <br /> Certificate Holder named herein,but failure to mail such notice shall impose no obligation <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, NC 27278 <br /> By: Collin Klein, Underwriting I - I <br /> Technician for the NCACC 7/12/2016 <br /> Certificate Mailed/E-Mailed or Faxed to: <br /> Orange County Dept. o Social <br /> Services <br /> P.O. Box 8181 <br /> Hillsborough, NC 27278 <br />