2018-319-E DSS - Personalized patient home assistance in home aide services

Browse Search

DocuSign Envelope ID: A07C4620 -D9FO- 4228- 9B2F- lD499E5F8796 ACC)R"° CERTIFICATE OF LIABILITY INSURANCE PATF-(MM/DDNYYY) 7110018 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 polley(les) 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($). PRODUCER HANOVER EXCESS & SURPLUS, INC. P.O. Box 12456 Wilmington, NC 28405 -0119 CONTACT NAME SANFORD INSURANCE COMPANY PHONE (A/C No, Ext): (919) 775 -7216 FAX (A/C No): (855) 4668697 EMAIL ADDRESS: csnria'd@sanfbrdinsurence.corn INSURER($) AFFORDING COVERAGE — NAIC # INSURED Dorothea Farrington Personalized Patients Home Assistance 109 Concord Dr Chapel Hill, INC 27516 INSURER A: United States Lfabllity Insurance Company 25895 INSURES B: 07/1712018 7 INSURER C EACH OCCtJRFNCE $ INSURER D: pqQt�Ay�� 7QQ��{? INSURER E: MED EXP (Any ona parson) $ INSURER F: PERSONAL & ADV INJURY $ COVE AOI=R CERTIFICATE NUMBERS 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 OFANY CONTRACT OR OTHER DOCUMENT 1MTH RESPECT TO WHICH THIS CERTIFICATE MAY BE MSUED 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 A TYPE OF INSURANCE I ADDL S SUBR P POLICY NUMBER I POLICY EFF P POLICY £3(P WMITS GENERAL LIABILITY p AH 15557,97$ 0 07/1712018 7 711712019 P EACH OCCtJRFNCE $ $1,0006.000 pqQt�Ay�� 7QQ��{? S101i200 MED EXP (Any ona parson) $ $51= PERSONAL & ADV INJURY $ $5,000;000 GENERAL AGGREGATE $ $3.000.000' PRO lCT$-COMPIOPAGG I Induded GEN'L A AGGREGATE LIMITAPPLIES PER P $ AUTOMOBILE L LIABILITY C C4 ec PtPINGLE LIMIT $ $ INJURY (Per person} $ $, BAADLY INJURY (Per eccident $ $ { er0 aCR YIDAMAGE $ $ f $ UMBRELLA LIAR O OCCUR E EACH OCCURRENCE $ $ AGGREGATE S S DIED R RETEN7nON $ - - WORKERS COMPENSASION T NIA E TO Y 1J ITS E.L.. EACH ACCIDENT S S E -L. DISEASE -EA EMPLOYEE S S E.L. DISEASE -POUCY LIMIT S S A L Allied Healthcare Professional E AH 1555797$ 7 7117/2018 7 7/1712019 A EACH CLAIM $ $140G'00ti' ANNUAL AGGREGATE $ $3,000,DOD_ DEDUCTIBLE EACH CLAIM $ $Q' DESCRIPTION OF OPERAT90NS1 LOCATIONS I VEHICLES (See attached Acord 101 for additional liability. Ilmtsj HOME HEALTH AIDE I I F If --AIA H1 I)"" 4l Nl CLLR AVIV ORANGE COUNTY DSS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED. 13EFOR E THE PO BOX, 8181 EXPIRATION DATE THEREOF, NOTICE VVILL BE DEUVERED IN ACCORDANCE WITH THE HILLSBOROUGH, NC 27278 POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r ACORD 25 (2010105.) Copyright 19$6-2010 ACORD CORPORA l' IUr Ignts reserver. The ACORD name and logo are registered marks of ACORD. ACORD 25 (2010105.) Copyright 19$6-2010 ACORD CORPORA l' IUr Ignts reserver. The ACORD name and logo are registered marks of ACORD.