2019-489-E DSS - Flaircare Inc. contract amendment

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DocuSign Envelope ID: DBC2D3D5-DDD6-4D1 D-8ED6-DF3ABF2B2278 ^1 FLAIINC-01 ,a►CtoRo CERTIFICATE OF LIABILITY INSURANCE DATOIYY1Yl 7/18/218/2019 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 1NSURER(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 endorsements. PRODUCER rRNjACT Deborah Mason Summers Thompson Lowry,Inc. (A?c°: No,Ext:(919)969.5322 FAC Nu: 919 942-4221 2113 Cameron Street Suite 219 debbie@stlinsure.com Raleigh,INC 27605-1370 INS UR>"R S AFFORDING COVERAGE NAfC# INSURER A!ACE American Insurance Co 22667 INSURED INSURER s:AllmeriCa Financial Benefit 41840 Flaircare,Inc DBA INSURER C:Accident Fund National ins Co. 12306 Hamewatch Caregivers 1210 SE Maynard Rd.Suite 202 INSURER D: Cary,NO 27511 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 IyPE OF INSURANCE ADDL SUeR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A �Pxo' MERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR MLP G27939694 004 1/1/2019 1/1/2020 DAMAGE TO RENTED 100,000 MED EXP A.ny one rscn PERSONAL&ADV I NJU RY S 1,000,000 GENLAGGREGATE pU�MpIT.APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POUCY JECT LOC PRODUCTS-COMPIOPAGG S 1,000,000 OTHER B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 lima accidents S ANY AUTO AW60229198 4/18/2019 4/18/2020 BODILY INJURY Per personj S AOVTQS ONLY LE AAUUpTTOSS1JUy ED❑ SOROILY INJURY(Per accident) S Ix AUTOS ONLY r AVTOS ONLY ?eraacEciR,t MAGE S 11 UMBRELLA LIAB OCCUR EACH OCQ V EN E E10ESS LIA6 HCLAIMS-MADE AGGREGATE Ii DEED I RETENTION$ C WORKERS COMPENSATION x PER OTH- AND EMPLOYERS'LiABIUTYER ANY CCPRROR��PMMRIETggO��RR�JPARTN ERIEXECUTI V£ Yf N CV801303904 11112019 111I2020 L.EACH ACCIDENT S 500,000 andatnryn N!f}ExCWOEl7? hllA 500,000 E.L.DISEASE-EA EMPLOYE If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ A Abuse/Sex Molestatio MLP 027939694 004 1/1/2019 1/1/2020 Per Claim 1,000,000 A General Liability MLP G27939694 OQ4 1/112019 1/112020 Per Aggregate 3,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached If more space is requi red I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County De of Social Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 tY Department ACCORDANCE WITH THE POLICY PROVISIONS, PO BOX 8181 Hillsborough,NC 27278 A UrTHORf=REPRESENTATIVE dtDrl I R S,.'S ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD