2018-551-E Health - Leading to Change service agreement

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DocuSign Envelope ID: F814C4A7- 100C- 424D- A226- 6FA7B02096C1 / AC� °® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 11812018 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 Liberty Mutual Insurance PO Box 188065 Fairfield, OH 45018 CONTACT NAME, PHONE FAX A/C No Ext : 800 - 962 -7132 Alc No): 800 - 845 -3666 E -MAIL ADDRESS: BUSlnessServlce Libert Mutual.com INSURER(S) AFFORDING COVERAGE NAIC # 8/21/2017 INSURERA: American States Insurance Company 19704 $1,000,000 INSURED Leading To Change Inc 9815 Samfurr Road 103 INSURER B : $1,000,000 INSURER C: MED EXP (Any one person) INSURERD: Huntersville NC 28078 INSURER E : $ excluded GEN'L INSURER F: GENERAL AGGREGATE $ 2,000,000 COVERAGES CERTIFICATE NUMBER: 39781630 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ✓ OCCUR 010172675450 8/21/2017 8/21/2018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence) $1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ excluded GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- P ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 ✓ PRODUCTS - COMP /OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Leading To Change Inc g 9 9815 Samfurr Road 103 Huntersville NC 28078 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 David Campbell ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 39781630 1 3538661971 1 17 -18 Master Certificate I David Campbell 1 1/8/2018 9:97:97 AM (EST) I Page 1 of 1