2018-575-E Health - Youth Empowered Solutions coaching program

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DocuSign Envelope ID:2A186D1A-DCOC-4AF3-A358-6DD18C89D561 v ucna�r. r 1 VJJJJ U4Tlll.1 1 t1CIV111,11 DATE(MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 9/04/2018 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 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: McGriff Insurance Service PHONE ggg 743-2217 FAX 8888279861 A/C,IN Ext: A/C,No 414 Gallimore Dairy Road E-MAIL ADDRESS: Suite F INSURER(S)AFFORDING COVERAGE NAIC# Greensboro, NC 27409 INSURER A Alliance of Nonprofits Ins RRG 10023 INSURED INSURER B:Hartford Casualty Insurance Company 29424 Youth Empowered Solutions (YES!) INSURER C 4021 Carya Dr Ste 160 INSURER D Raleigh, NC 27610-2914 INSURER E 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 FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 SUB POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DD • COMMERCIAL GENERAL LIABILITY 201822298 1/01/2018 01/01/201 EACH OCCURRENCE $1,000,000 CLAIMS-MADE � OCCUR PREMISES ERENTED nce $110001000 MED EXP(Anyone person) $20,000 PERSONAL&ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ • AUTOMOBILE LIABILITY 201822298 1/01/2018 01/01/201 Eaaociden SINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY Per accident $ A X UMBRELLA LIAB X OCCUR 201822298UMB 1/01/2018 01/01/2019 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 D I X RETENTION$10,000 $ B WORKERS COMPENSATION 22WBCDO9075 01101/2018 01/01/2019 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE R ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) **Workers Comp Information ** Proprietors/Partners/Executive Officers/Members Excluded: CORNWELL, THOMAS, ELECOFC JONES, HEATHER, ELECOFC REEVE, REBECCA, ELECOFC (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION The Orange County Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department ACCORDANCE WITH THE POLICY PROVISIONS. 300 West Tryon St. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 2 The ACORD name and logo are registered marks of ACORD