2018-146-E Health - Screenvision Media Quitline Service Agreement FY 17-18

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DocuSign Envelope ID: BDB2273F- FE44- 4C87- 97D8- 2B8FA11C507D A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD /YYYY) I 04/27/2018 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Aon Risk Services Central, Inc. Indianapolis IN office CONTACT NAME: (A/C.NNo. Ext): (866) 283 -7122 A/C No.): (800) 363 -0105 E -MAIL ADDRESS: 450 East 96th street Suite 275 INSURER(S) AFFORDING COVERAGE NAIC # Indianapolis IN 46240 USA INSURED INSURERA: Valley Forge Insurance Co 20508 Screenvision, LLC INSURER B: Transportation Insurance Co. 20494 1411 Broadway, 33 FL New York NY 10018 USA INSURER C: National Fire Ins. Co. of Hartford 20478 INSURER D: INSURER E: DAMAGE TO RENTED PREMISES Ea occurrence $300,000 INSURER F: MED EXP (Any one person) $5,000 COVERAGES CERTIFICATE NUMBER: 570070970945 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM /DD/ POLICY EXP MM /DD /YYYY LIMITS '4 X COMMERCIAL GENERAL LIABILITY 5 5 1 1 14 17 14 EACH OCCURRENCE $1,000,000 CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $300,000 MED EXP (Any one person) $5,000 PERSONAL &ADV INJURY $1,000,000 GEMLAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY ❑ PRO ❑ LOC JECT PRODUCTS- COMP /OP AGG $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY ( Per person) ANYAUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLY AUTOS HI RED AUTOS NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE Per accident UMBRELLA LIAB EACH OCCURRENCE AGGREGATE EXCESS LIAB HOCCUI CLAIMS -MADE DED RETENTION B C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR / PARTNER I EXECUTIVE OFFICER /MEMBER EXCLUDED? N (Mandatory in NH) N/A wc596080169 A05 wc595969328 CA 10/14/2017 10/14/2017 10/14/2018 10/14/2018 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ©1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2 aD L N 2 0 2 U) LOV 0 rn 0 0 0 LO O Z d R V w N U 7y y_ AN yri SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Orange County Health Department AUTHORIZED REPRESENTATIVE 2501 Homestead Rd. Chapel Hill NC 27516 USA ©1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2 aD L N 2 0 2 U) LOV 0 rn 0 0 0 LO O Z d R V w N U 7y y_ AN yri