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DocuSign Envelope ID:695BA350-46C5-40DD-8F45-F768C9663EB4
<br /> I
<br /> .�.--- 'mogil, KAHCA-1 OP ID: KJ
<br /> '`���'�0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOYYVY)
<br /> o6/1ar2a17
<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 ETWEEN THE ISSUING INSURER
<br /> IS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT (S), AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. •
<br /> .
<br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
<br /> If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br /> PRODUCER NA E:
<br /> 828-396-3342 coTACT Tony McCroskey,CIC
<br /> Granite Insurance Agency,Inc. PRO 828-396-3342 F^% 828-396-3834
<br /> 56 North Main Street ANC, 0,EA.: [Arc,No}:
<br /> Post Office Drawer 620 E-MIL tmccroskey @graniteinsurance.com
<br /> Granite Falls,NC 28630-0620 ADD,E$s.
<br /> Tony McCroskey,CIC INSURER(s)AFFORDING COVERAGE NA1Cif
<br /> INSURERA:StarNet insurance Company _
<br /> INSURED KAH Care, LLC INSURER B:Synergy Insurance Company 12773 l
<br /> DBA Right at Home
<br /> INSURER C: •
<br /> 4905 Pine Cone Drive,Suite 2
<br /> •
<br /> Durham,NC 27707 INSURER O: .....
<br /> •
<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 /> =DDLSU9R POLICY EFF POLICYE%P
<br /> INSR TYPE OF INSURANCE � O � POLICY NUMBER _(MMlDDIYYYY)�MMfnOlYYYY1 LIMITS
<br /> -
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE I X I OCCUR HHS 856798040 02/16/2017 02/16/2018 DAMAGE TO RENTED 100,000 PREMIS DAMAGE Ea oc
<br /> MED EXP(Any one person) $ -.
<br /> 5,000
<br /> PERSONAL&ADV INJURY
<br /> 1,000,000
<br /> 3,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: AGGREGATE $ 3,000000,
<br /> COMPIOP AGG
<br /> POLICY I j��T I �LOC ._ _. _ PRODUCTS f
<br /> OTHER: $
<br /> COMBINED SINGLE LIMIT 1,000,000
<br /> A AUTOMOBILE LIABILITY grident) $
<br /> ANY AUTO _ HHS 856798040 02/16/2017 02/16/2018 BODILY INJURY(Per person) S.
<br /> OWNED SCHEDULED
<br /> AUTOS ONLY AUTOS BODILY INJURY{Per a cddent) $
<br /> AOS ONLY X ALOW r OPJeMAGE $ - --
<br /> °
<br /> I I UMBRELLA LIAB OCCUR EACH OCCURRENCE $
<br /> ' EXCESS LIAB CLAIMS-MADE AGGREGATE -„_ $
<br /> I-
<br /> DED RETENTIONS $
<br /> B AND EMPLOYERS'COMPENSATION PERTUTE 0TH
<br /> ANY PROPRIETORJPARTNERIEXECUTIVE Y N WC100-000481-116 05/05/2017 05/05/2018 1,000,000
<br /> E.L.EACH ACCIDENT $
<br /> FICER/MEMCER EXCLUDED? I N 1 A 1,000,000
<br /> andalory In NH} . E.L.DISEASE-EA EMPLOYER$
<br /> If yes,describe under 1,000,000
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
<br /> A Crime HHS 8567980-10 0211812017 02/16/2018 Empl Thef
<br /> 25,000
<br /> A Abuse/Molestation HHS 8567980-10 02/16/2017 02/16/2018 1,000,000 3,000,000
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached if more space is required)
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> ORANG-1
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Orange County Department of
<br /> Social Services
<br /> PO Box 8181 AUTHORIZED REPRESENTATIVE
<br /> Hillsborough,NC 27278 ` . .,X. 4LAt-IA-a-Irp.._.
<br /> i "mil
<br /> ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD
<br />
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