2018-435-E DSS - SHI-ORANGE LLC nonemergency medicaid transportation services

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DocuSign Envelope ID: AA1647C8 -8778- 4021- 9E83- EDC4C913A37C f� AMLIV -01 RESJEI f��" DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 0a1o21201s 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 C A cT Jessica Reiser Alliance Insurance Group Arlc N , Mdj: (AIC, No), 941 Oak St. . es.reiser allianceins r com Euctene, OR 97401 E I ] 9 P• INSURED The Stratford LLC 405 Smith Level Rd Chapel Hill, NC 27516 �nt,r�oArcc rCOVIVIrA'TC MJIUCar -D• RFVICIArd NIIM RFR- 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. INSR TYPE OF INSURANCE ADDL SUBR POLICYNUMBER POLICYEFF POLICY EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY X CLACMSlu1AmE OCCUR X $25,000 Deductible X NSC100326 0810112018 08101/20/9 EACH OCCURRENCE 1,000,000 DAM AGE TO RENTED urreGoj $_ _ 200,406 ME EXP (Any one arson 5,000 I PERSONAL &ADV INJURY 1,000,000 X Per Claim GENERAL AGGREGATE 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; POLICY E] .wa F—x] LOC PRODUCTS - COMPIOPAGG 31000MO ANNUAL AGGREGAT 151000,000' OTHER: A OMOBILE LIABILITY UT COMBINED SINGLE LIMIT 11000,000 BODILY INJURY Per arson X ANY AUTO x 0337309 -09- 125201 08101/2018 0810112019 OWNED SCHEDULED AU��IT��O$ ONLY AUTOS SOOlLY INJURY Paraccldent $ _RoP c dent 11E IS �p '_ Ai1T�1S ONLY AUTOS ONNLY rx $ C X UMBRELLALIAB OCCUR EACH OCCURRENCE 6,000,000 EXCESS LIA® CLAIMS-MADE X J 2USC30405502 0810112018 08101 {2019 X 6RGREGATE 6,000,000 DED X , RETENTION$ 26,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PRgO�PR IETORIPARTNEWEXECUTIVE {AMandatary In NH} EXCLUDED? N/A PER OTH- Es - -$� E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE E.L. DISEASE - POLICY LIMIT If yes, des -tribe under DESCRIPTION OF OPERATIONS below A General Liability - NSC100326 08101/2018 OB10112019 $1M Per Incident/Agg _ 3,000,000 A PL Deductible • E NSC100326 0810112018 08101.12019 Per Claim 25,000 DESCRIPTION Or OPERATIONS ✓' LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be atlacbed It more space Is requlred) Coverage placed with National Fire & Marine Insurance Company are Issued pursuant to the surplus lines law and does not have the protection of state guaranty or insolvency funds nor has the policy wording been reviewed by the insurance department of the state. Terrorism Coverage Is Included. UMBRELLA COVERAGE IS EXCESS OVER: General & Professional Liability, Employee Benefits, Auto Liability, and Employers Liability. SEE ATTACHED ACORD 101 Orange County Local Government PO Box 8181 Hillsborough, NC 27278 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE jl�lt 4 ACORD 25 (2016103) @ 1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD