2018-056-E DSS - Express Support Group In-home aide services

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DocuSign Envelope ID: OF93300E -D182- 4824- AB97- AB4A8DFC99A5 T ® DATE (MMIDDNYYY{ AC" R" CERTIFICATE OF LIABILITY INSURANCE 05131!2017 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, SubjOCt 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). pRaoucER Piedmont Insurance Associates PO BOX 406, Huntersville, NC 28070 NAME IT Jennifer Goodman PHONE 887 -3901 ac No:_(888) 236.0940 Arc 0 Ext: ( 704 ) E -MAIL ADDRESS: jgoodman@pledmont-ins.com INSURER(S)AFFOROINGCOVERAGE NAICN INSURFRA: Colony Insurance Co. POLICY EXP MMIDDIYYYY INSURED Express Support Group LLC DBA Express Support Group Home Care 1801 St Albans Or Ste G Ra ei h NC 27609 INSURER B. Patriot National X INSURERC: INSURER D: AP515946 INSURERE - 0312712098 INSURER F: S 1,000,000 IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. 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. - TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF MMIODNYYY POLICY EXP MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY AP515946 03/27/2017 0312712098 EACH OCCURRENCE S 1,000,000 PREMISFa Eaoccunence $ 50,000 rA CLAIMS -MODE � OCCUR MED EXP (Any one person) $ 2,500 PERSONAL &ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; GENERALAGGREGATE S LL% 'OOO PRODUCTS- COMPFOPAGG $ i'000,000 X POLICYY IRI LOC S OTHER: EaaalldeDSlNGLE MIT S AUTOMOMLE LIABILITY BODILY INJURY(Perperson) S ANYAUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUfOSONLY AUTOS HIRED NON - OWNED PROPERTY 1) AGE P!AGGREGATE reocldent AUTOS ONLY AUTOSONLY S UMBRELLA LIAB OCCUR HOCCURRBJCE $ $ EXCESS LIAB CLAIMS -MADE OED RETENTION$ _ STATUTE �RH S WCP102124601GIC 01/12/2017 01!1212018 E.L. EACHACCIDENT $ 100,000 AND EMPLOYERS LIARIOFY YIN ANY OFRCERIMEMBER EXCLUDED? PROPRIETOMPARTNEWEXECUTIVE NIA E.L. DISEASE - EA EMPLOYEE $ 100,000 (Mandatary €n NH) Ilyes, describe urxlar 5500,000 DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ A SexuallMolestation AP515946 03/27/2017 03/27/2018 $1,000,000 DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) CA Mar! I A III VV C ER i FICA I C nV r -L1Gr% SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Social Services ACCORDANCE WITH THE POLICY PROVISIONS. 113 Mayo St AUIHOR€ZED REP ESENTATIVE JLG a Hillsborough, NC 27278 LJ'lyiSt7-LU'iO H�.VRN �JVRf VrVirrvr`1. nrr eryrrw reae,raa.. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Printed by JLG On May 31, 2017 at 01:03PM