2019-348-E DSS - KAH Care-Right at Home contract amendment

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DocuSign Envelope ID:4B2345D6-005A-4A36-BAA2-26E7C59B79FA KAHCA-1 OPI '4Ca►�a CERTIFICATE OF LIABILITY INSURANCE DATE 12019 05/05/2019 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(les)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 endorsements. PRODUCER $28-396.3342 CONTACT Tony McCroskey,CIC NAM Granite Insurance Agency,Inc. PHONE 828-396-3342 FAx 828-396-3834 56 North Main Street AMC No,Exs: Alc No Post Office Drawer 620 E-MAI tmccros ey gran to nsurance.com Granite Falls,NO 23630-0620 Tony McCroskay,CIC INSURER S AFFORDING COVERAGE NAIC# INSURER A:Accident Fund Insurance Co. 10166 .Ifs, W81 INSURER B:StarNet Insurance Company FCA}i Care LLC DBA Right at Home INSURER C: 4905 Pine Cone Drive,Suite 2 Durham,NC 27707 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUREVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE DDL U$R POLICY NUMBER POLICY EFF POLICY ExP UNIM B x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 11000,000 CLAIMS-MADE FK aCCUR HHS 8567980-12 02/1612019 02/16/2020 DAMAGE TO RENTED S 100,000 B X Professional Liab HHS 8567980-12 02/16/2019 02/16/2020 MED EXP(Any one 5,000 1 M EA13M Agg PERSONAL&ADV INJURY 1,000,000 �'OTHEIRi L AGGRE TE LIMIT APPLIES PER: E ERAL AGGREGATE 3,000,000 POLICY17 j� LOC PRODUCTS-COMPIOP AGG S 3,000,000 B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ANY AUTO HHS 8567980-12 02/1612019 02/1612020 BOOILYINJURY Perperson)__ AAUr ONLY AUTSCHOS�y�ED❑ BODILY INJURY Per accident $ ALiT05ONLY X ONLY DrecEclR l MAGE UMBRELLA LIAB HOCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE A E TE OEU I I RETENTION$ A WORKERS COMPENSATION PSTATUTE ER ER OTH- AND EMPLOYERS'LIABILITY YIN V6188250 0610512019 05/05/2024 1,000,000 ANY GPR�OPREIETgO�Rr{MPARTNEPiFXECUTIVE NIA E.L.EACHACCIO NT sndatory Ia NVi EXCLUDED? E.L.DISEASE-EA EMPLOYEE S 1,000,000 f es,describe under 1,000,000 ❑ SCRIPTION OF OPERATION below E.L.❑ISEASE- LICY LIMIT B Crime/Emp Theft HHS 8567980-12 02/16/2019 02/16/2020 Crime/Emp 50,000 B AbuselMolestation HHS 85679BO-12 02/16/2019 02/16/2020 Abuse/Mol 1,000,000 DESCRIPTION Or OPERA TION51 LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ORANG-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Orange County Department of Social Services PO Box 8181 AUTHORIZED REP RESENTATIVE Hillsborough,NC 27278 L p�� r'C. ACORD 25(2016103) O 1988-(2/015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD