2017-627-E Co. Mgr. - NCCEH for LSA services for HMIS

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DocuSign Envelope ID: 364B59FA-42BE-4E61-913F-9E25D1 C7A94F AC o DATE(MM/DD/YYYY) T� ® CERTIFICATE OF LIABILITY INSURANCE M2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT DAVID BRASWELL NAME: INSURE PHONE (919)781-1115 FAX (919)783-6427 (A/C,No,Ext): (A/C,No): 2607 GLENWOOD AVENUE E-MAIL ADDRESS:DBRASWELL @INSURE-NC.COM PO BOX 31508 INSURER(S)AFFORDING COVERAGE NAIC# RALEIGH NC 27622 INSURERA:AUTO OWNERS INSURANCE CO 18988 INSURED INSURERB:TRAVELERS INDEMNITY CO OF AMERICA 25666 NORTH CAROLINA COALITION TO END HOMELESSNESS INSURER C: P 0 BOX 27692 INSURER D: INSURER E: RALEIGH NC 27611-7692 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1712005458 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 35658183 1/12/2017 1/12/2018 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 35658183 1/12/2017 1/12/2018 BODILY INJURY(Per accident) $ AUTOS AUTOS A NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X MUTE EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A B E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) IH-UB-1412X64-3-15 1/30/2017 1/30/2018 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ORANGE COUNTY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P O BOX 8181 ACCORDANCE WITH THE POLICY PROVISIONS. 200 S CAMERON STREET HILLSBOROUGH, NC 27278 AUTHORIZED REPRESENTATIVE DAVID BRASWELL/DAVID ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)