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DocuSign Envelope ID: 147BE359-9EE3-4364-92AB-6619CE690DOB
<br /> ® DATE IM MID DIYYYY)
<br /> ACCDOR V CERTIFICATE OF LIABILITY INSURANCE
<br /> 612112019
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br /> certificate holder In lieu of such endorsements).
<br /> PRODUCER CONTACT
<br /> NAME: Ma re La axon
<br /> Miller&Miller Insurance Agency Inc PHONE FAX
<br /> 720 Commerce Street , 914-741-6400 A1C Ne:914-741-6407
<br /> TFlornwood NY 10594 EOARIL$ : Mar leL Miller-Ins,com
<br /> INSURER S AFFORDING COVERAGE NAIC H
<br /> INSURER A:ACE AMERICAN INSURANCE COMPANY 22667 _
<br /> INSURED PREM14 INSURER a:National Continental Ins _ 10243 _
<br /> Premier Home Health Care Services Inc INSURERC:COVERYS SPECIALTY INSURANCE COMPANY 15686
<br /> 1 North Lexington Ave,S#200
<br /> White Plains NY 10601 INSURERD:CHARTER OAK FIRE INS CO 25615
<br /> INSURERS:TRAVELERS IND CO 25658
<br /> INSURER F: Hiscox Insurance Company Inc 10200
<br /> COVERAGES CERTIFICATE NUMBER:1314738887 REVISION NUMBER:
<br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT'ro WHICH THIS
<br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br /> INSR TYPE OF INSURANCE IN
<br /> L BR POLICY NUMBER MMIDOPOLICY
<br /> LTR IYYYY MMIDDNYYY LIMITS
<br /> A GENERAL LIABILITY MLPG28210551003 21212019 2/212020 EACH OCCURRENCE $1,000,U00
<br /> x COMMERCIAL GENERAL LIABILITY P EMGES(Ea Otto e a t 50,000
<br /> CLAIMS-MADE Fx-]OCCUR i MED EXP(Any one person) $5.000
<br /> X PROF-CLAIMS MADE PERSONAL&AD11INJURY $1,DDD,000
<br /> X SEXUAL ABUSE GENERAL AGGREGATE $3,000.000
<br /> GEN%AGGREGATELIMITAPPLIESPER: PRODUCTS-COMPICPAGG $1,000,600 _
<br /> POLICY F PRD- LCC Prof Aggregate Limit $3,000,OD0
<br /> B AUTOMOBILE LIABIUTY CNY00070629938 212120t9 2/212020 COMBINED SINGLE LIMIT
<br /> Ea accident$ 5 1.0m,000
<br /> ANY AUTO BODILY INJURY(Per person) S
<br /> ALL OWNED SCHEDULED 800ILY INJURY(per ocalden!) $
<br /> AUTOS AUTOS
<br /> NON-OWNED PROPERTY DAMAGE $
<br /> X HIRED AUTOS X AUTOS ere iden!
<br /> C X UMBRELLA LIAB OCCUR OOSNY000026117 212/2019 212=20 EACH OCCURRENCE $25,W0,000
<br /> EXCESS LIAO x CLAIMS- 00
<br /> MADE AGGREGATE $25,0 ,00D
<br /> RDE❑ i X RETENTION$10 000 SEXUAL ABUSE $10 000 000
<br /> I
<br /> WORKERS COMPENSATION N U80N253D781951K GI30120 6130I2020 x WC STATU- OTH-
<br /> E AND EMPLOYERS'LIABILITY YIN U89M8461691951R 6/30/269 6130/2020
<br /> ANY PROPRIETORIPARTNERIEXECUTIVE N 1 A E.L,EACH ACCIDENT $1,000,000
<br /> OFFICERIMEMBER EXCLUDED? FN]
<br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
<br /> F Employee Theft UC2118450519 2/812019 V612020 Limit $50,00D
<br /> DESCRIPTION OF OPERATIC NSI LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedute,II more space Is required)
<br /> "Policies shown are subject to terms,conditions,exclusions,sublimits and deductibles not listed on this certificate. We recommend that requests for policy
<br /> copies be directed to the Named Insured shown above.*
<br /> Work Camp Policy #UBON2530781951 K-Covers the fallowing States-CT,GA, ,IL,MA, NJ,NY,NC,OK
<br /> Work Comp Policy# UB9M8461691951 R -Covers the following States-FL,MA
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE,ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> ACCORDANCE WITH THE:POLICY PROVISIONS.
<br /> Orange County Department of Social Services
<br /> 113 Mayo Street AUTHORIZED RE ESENTATiVE
<br /> Hillsborough NC 27278
<br /> ©1988-2010 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
<br />
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