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

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DocuSign Envelope ID: A07C4620 -D9F0- 4228- 9B2F- 1D499E5F8796 -1 0 A o CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDPIYYYY) 0710912018 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 -- Sanford Insurance Center 1722 S HORNER BLVD SANFORD NC 27334 CONTACT Carla Dubuc NAME: PHONE,.,,: (919) 775 -7216 c Nd ; (888) 280 -1697 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: National Llabllity and Fire COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F1 OCCUR INSURED -- -- - Personalized Patients Home Assistance, DBA: Dorothea Farrington 109 Concord Dr Chapel HIII NC 27516 INSURER B : INSURER C: INSURER 0: $ INSURER E: DAMAGE TO RENTED PREMISES Ea o=ranco INSURER F - COVERAGES CERTIFICATE NUMBER: CLI87904847 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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, INSR LTR TYPE OF INSURANCE INS WVO POLICYNUMBER _ POLICY EPF MWDDN -"Y POLIO P MMIDDNYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F1 OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea o=ranco $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMITAPPLIES PER: PO- POLICY El ,IEC ❑ LOC OTHER: G EN ERAL AGGREGATE $ PRODUCTS - COMPIOPAGG $ $ AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident $ BODILY INJURY (Per parson) $ BODILY INJURY (Par accldent) $ PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAR EXCESS LI'AB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORMARTNER/EXECUTIVE OFFICERIAIEMSEREXC'LUDED7 ❑ (Mandatory In NH) IF yes, descrlbe under DESCRIPTION OF OPERATIONS below NIA A9WC9fi7434 D7105l2Q18 07105l2Q19 PER OTH- STATUTE ER _ E.L. EACH ACCIDENT $ 100.000 E,L. DISEASE - EA EMPLOYEE $ 1 DD,DDD E.L. DISEASE - POLICY LIMIT 50D,00D $ DESCRIPTION OF OPERATIONS/ LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) 4CK 1i t-IUA It I'1UL'llt:K U. 144 CLLHI IU14 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County DSS ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough NC 27278 O 1988 -2015 ACORD CORPORATION. Alf rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD