2018-381-E DSS - MediSolutions in-home aide services

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DocuSign Envelope ID: 3E4B4B91- 8AA8 -41 OB- 8584- 11AAECCBC787 ® DATE (MMIDDIYYYY) n CERTIFICATE OF LIABILITY INSURANCE 07/24/2018 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 IN8URER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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(s). PRODUCER NAME: An ie Cox 161Q - Capital Insurance & Financial Services, Inc. PHONE 91$- 571.0585 FAX Noc 919 571 -0584 3701 Lake Boone Trail no RI ES ' aCtcC�ca Ital ins.cam Suite 200 INSURER(S)AFFORDING CDVERAGE NAIC6 Raleigh NC 27807 INSURERA: Ph1ladel ph ia Insurance Cam pan ies INSURED INSURERS: Travelers Medisolutions Inc INSURERC - 100 N Church St INSURER D: Suite B INSURER E: _ BURLINGTON NC 27217 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE huh; Ilya FULIL;Y i-'Orcltju 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. THE EXPIRATION HATE. THEREOF, NOTICE WILL BE DELIVERED IN OLICY EFF LIC EXP I "SR TYPE OF INSURANCE POLICY NUMBER MMIDoNyyy MhVDDfYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 f`. COMMERCIAL GENERAL LIABILITY PREMISES Eaaccurrance $ 100000 CLAIMS -MADE F—vil OCCUR MED EXP (Anyone person) $ 5000 A N N PHPI(1742845 11/22/2017 11/22/2018 PER SO NAL & ADV I NJU RY $ 1000000 GENERAL AGGREGATE $ 2000000 GGEEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGO $ 2000000 !. POLICY PRO- LOC $ C e eBciNd.n SINGLE LIMIT $ AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS DAMAGE Peracmden! $ HIRED AUTOS _ AUTOSNMED UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADF. DED I I RETENTION $ 4VORKE�RSCOMPENSATION X UVC O STA IT OTH- AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN -] NIA N 1158 11222017 11122J2017 11/2212018 E.L EACH ACCIDENT $ 100000 E.L DISEASE - EREMPLOYEE $ 100000 B 0FFICERIMEMBEREX.CLUDED7 (Mandaloryin NH) E.L DISEASE - POLICY LIMET _ $ 500000 - If s describe under DESCRIPTION Of OPERATIONS belc vl Professional Liability 1.000,000 each occurrence A N N PHPK174845 11/22/2017 1112212018 2,000,000 aggregate DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Attach ACORD 101, Additlanal Remarks Schedule, It morespace is required) nA Alf`CI I Ar!nKI %.Crt I IFI%.,n I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION HATE. THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Orange County PO BcK 8181 AUTHORIZED REPRESENTATIVE Hillsborough NC 27278 •++ CAM Mr- ACORD 25 (2010105) W I U0c-GV IV SL +J RLJ l VRFVnn i Tvrr. nn r IUL— , The ACORD name and logo are registered marks of ACORD