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DocuSign Envelope ID:4C3F4116-538F-4051-AC16-B880C7C5E276 <br /> As!soctm row 0F,Coutiwy 4 r0,ymmrsstt9sous <br /> . a RISK MANAGEMENT POOL S <br /> °p`r auwr Covering the Counties that Cover our State <br /> WORKERS COMPENSATION COVERAGE CERTIFICATE <br /> COVERAGE PROVIDER: <br /> NCACC Liability and Property Pool <br /> 215 North Dawson Street This certificate is provided by the NCACC Workers'Compensation Pool <br /> Raleigh,NC 27603 and is issued as a matter of information only. This certificate confers no <br /> MEMBER: rights upon the certificate holder other than those provided in the <br /> coverage document. This certificate does not amend,extend,or alter the <br /> North Carolina Alliance of Public Health Agencies coverage afforded by the coverage documents listed herein. <br /> 222 N. Person Street,Suite 208 <br /> Raleigh,NC 27601 <br /> COVERAGES <br /> Type of Coverage Coverage Effective Expiration <br /> Contract# Date Date Limits <br /> Coverage A: <br /> WORKERS'COMPENSATION <br /> WC-NC-456-17 July 1,2017 July 1,2018 Statutory <br /> Coverage B: <br /> EMPLOYERS'LIABILITY <br /> WC-NC-456-17 July 1,2017 July 1,2018 $2,000,000 <br /> Coverage C: <br /> OTHER STATES <br /> WC-NC-456-17 July 1,2017 July 1,2018 Statutory <br /> Additional Information: <br /> Evidence of coverage. <br /> CERTIFICATE HOLDER: Cancellation: Should any of the described coverage documents herein be cancelled before <br /> NCPHA the expiration date shown, the NCACC Pools will endeavor to mail written notice to the <br /> Certificate Holder named herein,but failure to mail such notice shall impose no obligation <br /> 222 N. Person St. or liability of any kind upon the NCACC Pools, its agents or representatives,or the issuer of <br /> Raleigh,NC 27601 this certificate. <br /> By: Collin Klein, Underwriting <br /> Technician for the NCACC 1. i.A"".• 4 J/U 6/30/2017 <br /> Certificate Mailed/E-Mailed or Faxed to: <br /> NCPHA <br /> 222 N. Person St. <br /> Raleigh, NC 27601 <br />