2016-586-E Finance - Senior Care of Orange County, Inc. - Outside Agency Performance Agreement

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DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357 Client#:955852 04SENIOCARI ACORDTM CERTIFICATE OF UAB L[TY INSURA• NCE DATE(MWDDNYYY) 9!02!2916 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 CONTICCT NAME: BB&T Insurance Services,Inc. PHONE 888 743-2217 FAX 8888279861 (AIC,No ExI): (FUG,No): 414 Gallimore Dairy Road E-MAIL Suite F ADDRESS: Greensboro,NC 27409 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Evanston Insurance Company 35378 INSURED INSURERB:Riverport Insurance Company 36684 Senior Care of Orange County Inc Attn Day Health Cent INSURER C: INSURER D: 105 Meadowland Dr. Hillsborough,NC 27278-8181 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 FEE LTR INSR,WVD POLICY NUMBER (MMIDDNYYY) IMMIODNYYY) LIMITS A X COMMERCIAL GENERALLIABIUTY SM914951 07/13/2016 07/13/2017 EACH OCCURRENCE 51,000,000 X CLAIMS-MADE OCCUR PREMISES(Eaccccurrence) 550,060 X BIIPD Ded:5,000 MED EXP(Any one person) 55,000 PERSONAL&ADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s3,000,000 PRO- POLICY -JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) • 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED 1 RETENTION$ _ _ $ pci B WORKERS COMPENSATION NCARP305328 02/08/2016 02/0812017 X ISr.MUTE I OTH- ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YlN E.L.EACH ACCIDENT $500,000 OFFICEWMEMBEREXCLUDED? [ Yl NIA (Mandatory In NH) EL.DISEASE-EA EMPLOYEE 5500,000 If yes,describe under DESCRIPTION OF OPERATIONS below F.L.DISEASE-POLICY LIMIT $500,000 A Sexual Acts SM914951 07/13/2016 07/13/2017 $100,000 occurence Liablity $300,000 aggregate DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Professional Liability-Pol.#SM914951 Professional Liability Limit#1:1,000,000 Ded.#1:$5,000.00 Limit#2:3,000,000 Retroactive Date:July 13,2005 for GL and PRO (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1Uf>1t.Cui OO 19813-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014(01) 1 of 2 The ACORD name and logo are registered marks of ACORD #S167622361M16521526 LRN