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DocuSign Envelope ID:E8163127-982F-4CDF-AAFE-9EAE17837984
<br /> PIEDMI7 OP ID: KB
<br /> AcoROw CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br /> 04/21/2017
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br /> certificate holder in lieu of such endorsement(s).
<br /> PRODUCER NAMEACT Kendra A. Biddle,CPCU, CIC
<br /> Senn Dunn-Charlotte
<br /> 440 South Church St.,Ste 500 PHONE
<br /> WC, Ext):336-899-2410 F"WC,No): 336-841-5319
<br /> Charlotte,NC 28202 ADDRESS: kbiddle @senndunn.com
<br /> M. Bryan Beasley,CIC
<br /> INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURER A:StarNet Insurance Co 40045
<br /> INSURED Piedmont Health Services Inc. INSURER B:AIX Specialty Insurance Co.
<br /> Lydia Mason
<br /> 299 Lloyd St. INSURER C:Allmerica Financial Benefit
<br /> Carrboro, NC 27510 INSURER D:
<br /> INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br /> INSR ADDL SUBR POLICY EFF POLICY EXP
<br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER /Y LIMITS
<br /> (MM/DD/YYYY) (MM/DD YYY)
<br /> B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE X OCCUR X L16-A734411-01 10/11/2016 10/11/2017 PRENEETO R
<br /> PREMISES(Ea occurrenceENTED ) $ 1,000,000
<br /> MED EXP(Any one person) $ 5,000
<br /> PERSONAL&ADVINJURY $ 1,000,000
<br /> GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000
<br /> POLICY PRO JECT X LOC PRODUCTS-COMP/OPAGG $ 3,000,000
<br /> OTHER. $
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
<br /> (Ea accident)
<br /> C X ANY AUTO AW6A534528-01 10/11/2016 10/11/2017 BODILY INJURY(Per person) $
<br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS AUTOS
<br /> NON-OWNED PROPERTY DAMAGE
<br /> HIRED AUTOS AUTOS (Per accident)
<br /> X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000
<br /> B EXCESS LIAB CLAIMS-MADE L16A734412-01 10/11/2017 10/11/2017 AGGREGATE $ 5,000,000
<br /> DED RETENTION$ $
<br /> WORKERS COMPENSATION X PER OTH-
<br /> AND EMPLOYERS'LIABILITY STATUTE ER
<br /> Y/N
<br /> A ANY PROPRIETOR/PARTNER/EXECUTIVE KEY0136292 02/01/2017 02/01/2018 E.L.EACH ACCIDENT $ 500,000
<br /> OFFICER/MEMBER EXCLUDED? N/A
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
<br /> B Professional L16-A734411-00 10/11/2016 10/11/2017 Incident 1,000,000
<br /> Liability CLAIMS MADE Aggregate 3,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> If required by written contract the following is an Additional Insured with
<br /> regard to General Liability coverage: The Susan G.Komen Breast Cancer
<br /> Foundation,Inc., North Carolina Triangle to the Coast Affiliate.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SUSANG2
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> The Susan G Komen Breast ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Cancer Foundation, Inc
<br /> NC Triangle to Coast Affiliate AUTHORIZED REPRESENTATIVE
<br /> 600 Airport Blvd,Suite 100
<br /> Morrisville, NC 27560 0 - a
<br /> ©1988-2014 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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