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DocuSign Envelope ID:BE949AA1-4694-4E6D-9DBA-90D729491FE0 <br /> Piedmont Health Services, Inc. <br /> 299 Lloyd Street <br /> Carrboro, NC 27510_ <br /> INSURANCE CERTIFICATION <br /> This is to certify that as of February 1, 2016, Piedmont Health Services, Inc. has <br /> the following insurance overages: <br /> Type of Insurance Company and Amount of Coverage Expiration <br /> Coverage Address Date of <br /> Policy <br /> 1 Commerical Package: Hanover American 2-1-17 <br /> General Liability Insurance Co. 3M/ 1M /3M <br /> Property Damage 440 Lincoln Street Replacement <br /> Abuse& Molestation Worcester, MA 01605 1M/5K/ 1 M <br /> Crime 3M/ 1M /3M <br /> Policy#:ZZ6A53449100 1M 1 1M <br /> 1 Commercial Package: Allmerica Financial Benefit 2-1-17 <br /> Automobile Policy Ins 1M/5K/1M <br /> CSL Liability 440 Lincoln Street <br /> Med Pay Worcester, MA 01605 <br /> UM/UIM <br /> Policy#AW6A534528 <br /> 1 Commercial Package: Hanover Insurance Group 5M/5mil aggregate 2-1-17 <br /> Umbrella Liability Policy 440 Lincoln Street <br /> Policy#:UH6A53449500 Worcester, MA 01605 <br /> Limit <br /> 1 Workmen's Allmerica Financial Benefit 500K/500K/500K 2-1-17 <br /> Compensation Ins <br /> Policy#: W26A52452500 440 Lincoln Street <br /> Employers Liability Limits Worcester, MA 01605 <br /> 1 Other: RSUI Indemnity Company 3M per claim/aggregate 2-1-17 <br /> Directors and Officers 945 E Paces Ferry Rd, Ste 3M per claim/aggregate <br /> Employment Practices 1800 1M per claim/aggregate <br /> Liability Limit Atlanta, GA 30326 <br /> Fiduciary Liability Limit <br /> Policy#: NHP655838 <br /> INSURANCE AGENTS: <br /> 1 <br /> Senn Dunn Insurance Co. <br /> 1400 Eastchester Drive <br /> High Point, NC 27265 <br /> (336) 878 -7800 <br /> e A—ed this 11th day of March 2016 <br /> .. A. •' % r/ <br /> LydiF. Mason, CFO <br /> Pied ont Health Services, Inc. <br /> 299 Lloyd Street <br /> Carrboro, NC 27510 <br />