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DocuSign Envelope ID: FB28FAE1-FFC6-4AE8-BB72-9CC28168D54E <br /> �• • iK 4 R,T Fg C A A n L i M A <br /> i] O 111 OCTATMN O}COl'NT7 C01HMS55Y[1M8P3 <br /> � y RISK MANAGEMENT POOLS <br /> cou+:Tc Cove Ong the Counties that Cd der our Va to <br /> WORKERS COMPENSATION COVERAGE CERTIFICATE <br /> COVERAGE PROVIDER: <br /> NCACC Liability and Property Pool <br /> 323 West Janes St.,Suite 500 This certificate is provided by the NCACC Workers'Compensation Pool <br /> Raleigh,NC 27603 and is Issued as a matter of Information only. This certificate confers no <br /> MEMBER: rights upon the certificate holder other than those provided In the <br /> coverage document. This certificate does not amend,extend,or alter the <br /> Chatham Transit Network coverage afforded by the coverage documents listed herein. <br /> 48a Hitlsboro Street,Suite 110 <br /> Pittsboro,NC 27312 <br /> COVERAGES <br /> Type of Coverage Coverage Effective Expiration <br /> Contract# Date Date Limits + <br /> Coverage A: <br /> WORKERS'COMPENSATION <br /> WC-CH-475-19 July 1,2019 July 1,2020 Statutory <br /> Coverage B: <br /> EMPLOYERS'LIABILITY <br /> WC-CH-475-19 July 1 2019 J uly 1 2020 12,000,000 <br /> Coverage C: <br /> OTHER STATES <br /> WC-CH-475-19 July 1,2019 July 1,2020 Statutory <br /> Additional Information: Evldemce of Coverage. <br /> CERTIFICATE HOLDER: Cancellation: Should any of the described coverage documents herein be cancelled before <br /> Orange County Government the expiration date shown, the NCACC Pools will endeavor to mall written notice to the <br /> Certificate Holder named herein,but failure to mail such notice shall Impose no obligation <br /> 200 South Cameron Street or I[abllity of any kind upon the NCACC Pools,its agents or representatives,or the Issuer of <br /> Hillsborough,NC 27278 this certificate. <br /> By: Willie J.Alien Jr., +ct� 513012fl19 <br /> Underwriter for the NCACC <br /> Certificate Mailed/E-!Nailed or Faxed to: <br /> Orange County Government <br /> 240 South Cameron Street <br /> Hillsborough,NC 27278 <br />