2019-636-E DSS - Charles House adult day care

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DocuSign Envelope ID: FBA030F0-9120-42B9-A272-5932D959B8F6 DATE(MMIDDrYYYY) CERTIFICATE OF LIABILITY INSURANCE 061201201 s 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 INSURERjS), 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 an this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT Michael Riggabee,Jr. Me Carolina National Insurance Agency PHONE (919)636-3252 FAX Ore PO Box 1028 ADoRL • luke cnia enc .cam INSURERS AFFORDING COVERAGE NAIC# Carrboro NC 27510 INSURER A: Philadelphia 18058 INSURED INSURER B: Carolina Mutual Insurance Company 14090 Charles House Association INSURER C: 7511 Sunrise Road INSURER D: INSURER E: Chapel Hill NC 27514 1NSURERF: 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 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 SEEN REDUCED BY PAID CLAIMS. INSR TYPE OF IN AODLISU9R Mfqn POLiCYN11MeER MPOLICY EFF PCLIICDY EXP LJMITS X COMMERCIALGENERALLIABLLITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 19 OCCUR ❑PFZr ISESO REaNcaTED fEance $ 100,000 MEP EXP(Any one arson) $ 5,000 A Y PHPK1958555 05110/2019 05/1012020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3.000,000 X POLICY PRO LOC PRODUCTS-COMPICFAGG $ 3,000,000 JECT $ OTHER: COMBINED AUTOMOBILE LIABILITY Ee accAden SINGLE LIMIT $ 1,000.000 ANY AUTO BODILY INJURY(Per person) S A AWNED SCHEDULED PHPK1958555 05110/2019 0511012020 BODILY INJURY(Paraccldanl] $ AUTOS ONLY AUTOS X HIRED NON-0WNE❑ PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accide l S UMBRELLA LIAB M OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIIIB CLAIMS-MADE PHUB669036 05/1012019 05110/2020 AGGREGATE $ 1,000,000 DE❑ I X I RETENTION$ 10,000 $ WORKERS COMPENSATION PaTERIUT E ERH AND EMPLOYERS'LIABILITY ANY P ROP RIETO RIPARTN ERIEX ECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 B OFFICERIMEMBER EXCLUDEDP ❑ NIA N WC23000-2019 06/25/2019 06/2512020 (Mandatory In NH E.L.DISEASE-EA EMPLOYEE S 500.000 "yes,describe under 500,000 DESCRIPTION OF OPERATIONS ba I I E.L.DISEASE-POLICY LIMIT S Each Claim $1,000,000 Professional Liability TI I q PHPK1958555 05/10/2019 0611012020 Aggregate $3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (A CORD 1al,Additional Remarks Schedule,may be attached Ir mare space Is required] CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBES]POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Government ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 AUTHORIZED REPRESENTATIVE Hillsbarou h NC 27278 Fax: Email, @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD