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DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 Liability Damage Liability $1 million Each Occurrence $1 million Each <br /> $1,000,000 Bodily $2 million Aggregate Occurrence <br /> Injury and Property $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 webpape 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 /> g) Solid Waste Program Fee (SWPF) Verification <br /> This fee finances Orange County's recycling and waste reduction program. Submit either a.) <br /> proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement <br /> on agency letter head indicating exemption and specify the person(s), business, etc. that is <br /> responsible for paying this fee. <br /> DO NOT SUBMIT THIS PAGE 1/27/2017 3:48:29 PM P g c 2G of 2G <br />