2017-340-E DSS - Personalized Patient Home Assistance, Inc. for in-home aides services

Browse Search

DocuSign Envelope ID: E51 E535C-F71 B-44A8-86D6-2EAB7FFA6A81 ' ACQ ® DATE(MWDDIVYYY) CO CERTIFICATE OF LIABILITY INSURANCE 6/30/2017 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(les)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 CONTACT Carla Dubuc Sanford Insurance Center PHONE (919)775-7216 I(p'c.Nol:(858)200-1697 JA/C.No.Exp: 1722 S HORNER BLVD EMAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 11 SANFORD NC 27330 INSURER A:Stonewoad Insurance Company INSURED INSURERB:United States Liability Ina. Co Personalized Patients Home Assistance, DBA: Dorothea INSURER C 109 Concord Dr INSURER D: INSURER E: Chapel Hill NC 27516 INSURERF: ' COVERAGES CERTIFICATE NUMBER:CL1763004392 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 W)TH 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 SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE IUD two POLICY NUMBER (MMIDDMYYY) IMMIDDIYYYYI x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 07/17/2017 07/17/2018 DAMAGE TO RENTED 100,000 B ■ AR 1555797 CLAIMS-MADE x OCCUR PREMISES Me occurrence) S ■ MED EXP(Any one parson) $ 5,000 ■ PERSONAL B,ADVINJURY 5 1,000,000 GEN"L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY I !Nei I LOC PRODUCTS-COMP/OP AGG $ Included OTHER: i AUTOMOBILE LIABILITY COMBINE- SINGLE LIMIT $ ■ ANY AUTO BODILY INJURY(Per person) S ■ AUTO L ANED SCHEDULED BODILY INJURY(Per sodden') S NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accldann S UMBRELLALIAB OCCUR EACH OCCURRENCE $ . EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION I PER I I ERH AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE 7 N E.L.EACH ACCIDENT S 100,000 OFFICER/MEMBER dtoyInNH)EXCLUDED? VC100-0059369-2017 7/1/2017 7/1/2015 E"L,DISEASE-EA EMPLOYEES 100,000 A (Mandatary In NH) If yes,dooci ba under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 B Professional Liab All 1555797 07/17/2017 07/17/2018 S1,000,IXI01$3,000,000 $0 Ded B Abuse/Moleet&tion All 1555797 07/17/2017 07/17/2015 $1,000,000152,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,AddlUonol Remarks Schedule,may be attached II more space le required) • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County DSS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Sanford Insurance Ce ID. atz.m- C4 it,-,cA , ©1888.2014 ACORD CORPORATION. All rights re rved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201451)