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DocuSign Envelope ID:881484B7-44A8-4DD9-9947-6209CB23CD79 <br /> 4C__"" DATE(MM/DD/YYYY) <br /> llh� CERTIFICATE OF LIABILITY INSURANCE 05/19/2019 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br /> HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE <br /> AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE <br /> ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS WAIVED, <br /> subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does <br /> not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT NAME: <br /> TOMPKINS INSURANCE <br /> 39320246 PHONE (866)467-8730 Fax (888)443-6112 <br /> (A/C,No,Ext): (A/C,No): <br /> PO BOX 6707 <br /> E-MAIL ADDRESS: <br /> WYOMISSING PA 19610 <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURERA: The Sentinel Insurance Company 11000 <br /> INSURED INSURER B: <br /> PATAGONIA HEALTH,LLC INSURERC: <br /> 15100 WESTON PKWY STE 204 <br /> CARY NC 27513-2129 INSURER D: <br /> INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 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 TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE <br /> TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS <br /> LTR INSR WVD MM/DD/YYYY MM/DD/YYYY <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 <br /> CLAIMS-MADE OCCUR DAMAGE TO RENTED $1 000 000 <br /> PREMISES Ea occurrence <br /> X General Liability MED EXP(Any one person) $10,000 <br /> A 39 SBM UQ5601 06/17/2019 06/17/2020 PERSONAL&ADV INJURY $1,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 <br /> POLICY❑PRO LOC PRODUCTS-COMP/OP AGG $2,000,000 <br /> JECT FXI <br /> OTHER: <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1 000 000 <br /> Ea accident <br /> ANY AUTO BODILY INJURY(Per person) <br /> A ALL OWNED SCHEDULED 39 SBM UQ5601 06/17/2019 06/17/2020 BODILY INJURY(Per accident) <br /> AUTOS AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE <br /> X AUTOS X AUTOS (Per accident) <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE <br /> EXCESS LIAB CLAIMS- AGGREGATE <br /> MADE <br /> DED RETENTION$ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY AT <br /> ER <br /> ANY Y/N E.L.EACH ACCIDENT <br /> PROPRIETOR/PARTNER/EXECUTIVE <br /> OFFICER/MEMBER EXCLUDED? NIA E.L.DISEASE-EA EMPLOYEE <br /> (Mandatory in NH) <br /> If yes,describe under E.L.DISEASE-POLICY LIMIT <br /> DESCRIPTION OF OPERATIONS below <br /> A EMPLOYMENT PRACTICES 39 SBM UQ5601 06/17/2019 06/17/2020 Each Claim Limit $10,000 <br /> LIABILITY Aggregate Limit $10,000 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> Those usual to the Insured's Operations. <br /> CERTIFICATE HOLDER CANCELLATION <br /> Patagonia Health Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br /> 202 MIDENHALL WAY BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED <br /> CARY NC 27513 IN ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> ©1988-2015 ACORD CORPORATION.All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br />