2019-632-E DSS - Senior Care of OC adult day care

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DocuSign Envelope ID: 179DC6FB-73BA-4F64-A513-C8AB2B7D864F Client#:955852 04SENIOCAR1 DATE(MMIDDIYYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 06129/2018 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 endarsement(s). PRODUCER CONTACT NAME: McGriff Insurance Services PHONE A!C No, o Ext 888 743-2217 uc No)., 8888279881 414 Galilmore Dairy Road EMAIL ADDRESS: Suite F INSURER s AFFOROI NG COVERAGE NAIC N Greensboro,NC 27409 INSURER A ra EvsnslonInsuncsCompsny 35378 INSURED INSURER B:M90*1 lnwraewCompany 38970 Senior Care of Orange County Inc INSURER C Attn Day Health Center INSURER D 105 Meadowlands Dr INSURER E Hillsborough, NC 27278-8181 INSURER F COVERAGES CERTIFICATE NUMBER: REWSION 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 ADDLSUBR pOLIC E F POLICYEXP LTR S WVD POLICY NUMBER (MI MWI] LIMITS A X COMMERCIAL GENERAL LIABILITY x SM921051 D711312018 07/1312019 E❑AACyHpGOEC7CURRENCE $1 DOD 000 x CLAIMS-MADE F-IOCCUR PREMISES !eEauu ence $550 000 X BI1PD Ded:5,000 MEDEXP(Anyone rsort) $5 Dad PERSONAL a ADV INJURY $1 000 000 rOTHER: L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3 000 000 POLICY PRO JECT LOC PRODUCTS-COMPIDP AGG $ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eeaced i ANY AUTO BODILY INJURY(Per peraon) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOSONLY AUTOS - HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ B WORKERS COMPENSATION MWC010610202 2/0812018 02/081201 XPER FR AND EMPLOYERS'LIABILITY -- ANY PROPRIETORIPARTNERIEXECLrrIVE YIN E.L EACH ACCIDENT $500 000 _ __ OFFICERIMEMSER EXCLUDED? N I A (Mandatory InNHJ E,LDISEASE-EAEMPLOYEE $500000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500 000 A Professional SM921051 7113/2018 07113/2019 $1,000,000 each claim Liability $3,000,000 aggregate $5,000 ded. DESCRIPTION OE OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached Irmore space Is required) Policy includes endorsement that provides Additional Insured status for any Landlord,Owner,or Property Manager of the Designated Premises or any Tradeshow or Convention Sponsor or operator or any lessor of equipment. Professional Liability-Pal.#SM921051 (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Orange County Government SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 9 Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 S Cameron Street ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE 1988.2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) 1 of 2 The ACORD name and logo are registered marks of ACORD #S204711011M20467370 WH9