2017-335-E DSS - Charles House Association for adult day care

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DocuSign Envelope ID: BADE4C5F-70BF-42D6-A88E-D4681BE4OBCA I _-, CHARHOU-01 MROBERTS AC©R©° DATE(M MIDDIYYYY) 4...------- CERTIFICATE OF LIABILITY INSURANCE 06/21i2017 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 have ADDITIONAL INSURED provisions or 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 NA CT CD Tg�E:.... _ ..__ _._.._.. Summers Thompson Lowry,Inc. PHONE FAX 100 Europa Drive (A/C No Exgp(919)968 44T2 (A/C,No):(919)942-4221 Suite 571 ADOREss:info @STLinsure.com Chapel Hill,NC 27517-2393 INSURES(S)AFFORDING COVERAGE NAICf1 INSURER A:Philadelphia Ins Co INSURED INSURER Et:Carolina Mutual Insurance Inc. House Association INSURER C: ._ . ... __.... ... Paul Klever 7511 Sunrise Road INSURER 0: Chapel Hill,NC 27514 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 " -_ ADDL SUBR POLICY EFF POLICY EXP - _...._. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYYI Ot1MIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000 000 Ii CLAIMS-MADE X OCCUR PHPK1650069 05/10/2017 05110/2018 DAMAGE TO RENTED PREMISES(Ea occurrence) 5 100,000 MED EXP(Any one parson) $ 5,000 PERSONAL& DV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRO- 3,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG S _ r I OTHER: $ J COMBINED SINGLE LIMIT A AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO PHPK1650069 05/10/2017 05/10/2018 BODILY INJURY(Per person) S 1,000,000 OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Peracddent) $ X VODS ONLY X AUTO ONLY (Per aca ntl AMAGE.._..............._.$--- A I X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 PHUB582933 05/10/2017 05/10/2018 1,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $._-.,....__...._"_ DED X RETENTIONS 10,000 $ B WORKERS COMPENSATION X STATUTE I `__..,,.I_0TH___._ AND EMPLOYERS'LIABILITY WC19056-2017 06125/2017 06/25/2018 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N1A E.L EACH ACCIDENT S FICERR/M MBER EXCLUDED? 50O,OOD andatory In NH) - E.L.DISEASE-EA EMPLOYE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S A iMolestation/Sexual PHPK1650069 05/10/2017 05/1012018 Aggregate 1,000,000 A Misconduct PHPK1650069 05/10/2017 05/10/2018 Occurrence 1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange Count Government THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 Y ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough,NC 27278 AUTHORIZED REPRESENTATIVE flne�{fl. a,5 1 ACORD 25(2016/03) 0 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD