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DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 6lA6E4C39BD2 <br />EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required <br />INSURANCE <br />TOWN OF CARRBORO <br />TOWN OF CHAPEL HILL <br />ORANGE COUNTY3 <br />Worker's <br />Limits for Coverage <br />Compensation' <br />A - Statutory State <br />Limits for Coverage A - <br />Limits for Coverage A - <br />NC, for each <br />Statutory State NC, for <br />Statutory State NC, for <br />employee <br />each employee <br />each employee <br />Limits for Coverage <br />Limits for Coverage B - <br />Limits for Coverage B - <br />B - Employers <br />Employers Liability of: <br />Employers Liability of: <br />Liability of: <br />$100,000 Each Occurrence <br />$500,000 each <br />$1 million Each <br />$100,000 BID for each <br />accident, $500,000 <br />Occurrence <br />employee <br />BID for each employee <br />$1,000,000 BID <br />$500,000 BID limit <br />$500,000 for BID limit <br />limit <br />Commercial <br />$100,000 Property <br />General <br />Damage Liability <br />$1 million Each Occurrence <br />$1 million Each <br />Liability <br />$1,000,000 Bodily <br />$2 million Aggregate <br />Occurrence <br />Injury ry and Property <br />$2 million Aggregate <br />Damage Limit <br />Automobile <br />Liability <br />Not Applicable <br />$1 million Each Occurrence <br />$500,000 Each <br />Occurrence <br />Professional <br />$1 million Each <br />Liability <br />Not Applicable <br />Not Applicable <br />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 />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 2/9/2017 4:31:06 PM Page 22 of 22 <br />