2017-640-E HR - Flexible Benefits Administrators, Inc. (FBA) to authorize FBA to work directly with Delta Dental

Browse Search

DocuSign Envelope ID:B156146B-0400-4433-84BD-A56E1 DCE5DA7 ..44C0/20® DAT 0(M 3/DDD1 ) CERTIFICATE OF LIABILITY INSURANCE 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 have ADDITIONAL INSURED provisions or 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 la= certificate does not confer rights to the certificate holder in lieu of such endorsement(s). . PRODUCER CONTACT 13 NAME: Aon Risk Services Central, Inc. PHONE FAX '-' Southfield MI Office (A/C.No.Ext): (866) 283-7122 (A/C.No.): (800) 363-0105 a 3000 Town Center E-MAIL p Suite 3000 ADDRESS: _ southfield MI 48075 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Allied World National Assurance company 10690 Delta Dental of North Carolina INSURER B: 4242 six Forks Road, suite 970 Raleigh NC 27609 USA INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570068354078 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. Limits shown are as requested INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR MD (MMIDD/YYYYI (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) J PERSONAL&ADV INJURY r GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY JECOT- I (LOC PRODUCTS-COMP/OP AGG el 0 OTHER: r AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT in (Ea accident) ANY AUTO BODILY INJURY(Per person) 0 z OWNED —SCHEDULED BODILY INJURY(Per accident) 01 AUTOS ONLY AUTOS al HIRED AUTOS NON-OWNED PROPERTY DAMAGE 0) ONLY —AUTOS ONLY (Per accident) F. l.. 0 w UMBRELLA LIAB OCCUR EACH OCCURRENCE U EXCESS LIAB CLAIMS-MADE AGGREGATE DED I RETENTION EMPLOY RS'COMPENSATION AND I PER ERH EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT OFFICER/MEMB ER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT A Cyber Liability 03101972 06/15/2017 06/15/2018 Each claim $10,000,000 Claims Made Aggregate Limit $10,000,000 M SIR applies per policy terns & conditions Retention $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 'rir- k Retro Date: 09/23/1957. a.a nail i' 71.! W CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ll a Brenda Bartholomew AUTHORIZED REPRESENTATIVE Orange County Human Resources Department 200 south Cameron street ar Hil lsborough NC 27278 USA (i clp cVs a M I. ®1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD