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DocuSign Envelope ID: B67A2C26-3304-4095-BB1C-73A2BC4A569A <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 <br /> below outlines insurance types and minimums required, for each jurisdiction. If exempt from <br /> Worker's Compensation compliance, include a statement explaining why, with the agency's <br /> application materials. *Note: If Approved for Funding: Approved agencies must provide an <br /> updated insurance certificate. The update should reflect the funding jurisdiction as an <br /> additional insured party and certificate holder and provide coverage for the duration of the <br /> funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 <br /> days prior to any expiration date, cancellation or modification of any stipulated insurance <br /> coverage. <br /> Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required <br /> INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 <br /> Worker's Limits for Coverage <br /> Compensation' A - Statutory State Limits for Coverage A - Limits for Coverage A - <br /> NC, for each Statutory State NC, for Statutory State NC, for <br /> employee each employee each employee <br /> Limits for Coverage Limits for Coverage B - Limits for Coverage B - <br /> B - Employers Employers Liability of: Employers Liability of: <br /> Liability of: $100,000 Each Occurrence $500,000 each <br /> $1 million Each $100,000 BID for each accident, $500,000 <br /> Occurrence employee BID for each employee <br /> $1 ,000,000 BID2 $500,000 BID limit $500,000 for BID limit <br /> limit <br /> Commercial $100,000 Property <br /> General Damage Liability $1 million Each <br /> Liability $1 ,000,000 Bodily $1 million Each Occurrence Occurrence <br /> $2 million Aggregate and Property <br /> $2 million Aggregate <br /> Damage Limit <br /> Automobile Not Applicable $1 million Each Occurrence $500,000 Each <br /> Liability Occurrence <br /> Professional $1 million Each <br /> Liability Not Applicable Not Applicable Occurrence <br /> $2 million Aggregate <br /> 1 . Visit the NC Industrial Commission's website for more information regarding Coverage A. <br /> Also, note that if an agency uses subcontractors, it must require subcontractors to have <br /> workmen's compensation insurance. <br /> 2. Bodily Injury by Disease (BID) <br /> 3. Please visit Orange County's contracts webpage for more information about the County's <br /> risk assessment procedures. <br /> f) List of Board of Directors <br /> Provide the following information about each board of director's member: name, telephone <br /> number, address, occupation or affiliation of each member and the list must identify the <br /> principal officers of the governing body, and length of term. <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 2:31 :06 PM Page I of °'I <br />