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DocuSign Envelope ID:6640lB51-89A1-4507-BCA8-FE809341297F <br /> Gocu$1gn�pe ID:147SE359-9EE3-4364-92AB-6619CE690DOB <br /> A`Q12o sr21/201r2a® CERTIFICATE OF LIABILITY INSURANCE DATE 1YYYY} <br /> 1s <br /> TH}S 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 pollcy(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 /> CONT <br /> AMACT Marie LaaxonPRoouoER ' <br /> Miller&Miller Insurance Agency Inc PHONE ,914-741-6460 FAX o:9'14-741-6407 <br /> 720.Commerce Street E-MAIL <br /> Thvrnwoed NY 1fl594 ADD Ess: Mar Ie Miller-Ins,com <br /> INSURERS AFFOR10ING COVERAGE NAIC N <br /> INSURER A:ACE AMERICAN INSURANCE COMPANY 22667 <br /> INSURED PREMI-4 INSURER B:National Continental ins 10243 <br /> Premier Home Health Care Services Inc INSURER C:COVERYS SPECIALTY INSURANCE COMPANY 15685 <br /> 1 North Lexington Ave,S#200 25615 <br /> White Plains NY'10601 INsuREft a;CHARTER OAK FIRE 1N5 CO <br /> INSURER E t TRAVELERS IND CO 25658 <br /> INSURER F:HIS=Insurance Ccmpaa 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, NOTWiTHSTANOiNG 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 1S SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INTRO ADOL S eft POLICY EFF POLICY ExP*R.1 <br /> 9JU <br /> Type OF INSURANCE POLICY NUMBER MIDO IDO <br /> A GENERAL LIAWLITY MLPG28210851003 2W2019 2f212020toao'sna <br /> x <br /> COMMERCIAL GENERAL LIABILITY S50,000 <br /> CLAIM54'r1P�0E �OCCUR X PROF-CLAIMS MADE <br /> X SEXUAL ABUSE GENERAL AGGREGATE $3,000.000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMKOP AGG $1=,000 <br /> POLICY PRO LOC Prof Aggregate Limit $3,000,00D <br /> B AUTOMOBILE L1ABtUTY CNY00070829928 21212019 2l2120213 COMBINED SINGLE LIMrr <br /> Es ODO 00 <br /> BODILY INJURY{Per person} $ <br /> ANY AUTO <br /> ALL OWNED SCHEDULED BODILY INJURY{Per accident} S <br /> AUTOS AUTOS PROPERTY DAMAGE <br /> X X NON-OWNED P Ida <br /> HIRED AUTOS AUTOS <br /> C x UMBRELLA LIAR DCCUR Oo5NYO0002S117 7.W2019 212/2020 EACH OCCURRENCE S 25 006 IDD <br /> EXCESS LIAR X CLAIMS-MADE <br /> AGGREGATE ;26 000,000 <br /> DED X RETENTION 10,000 SEXUAL ABUSE $ID 000,000 <br /> D WORK ERSCOMPENSATION N UBON253G781951K OM M2019 W3Wc20 X STATU- "TH- <br /> E AND EMPLOYERS'LIABILITY UB9MB461691951R OW2019 Gr30=20 <br /> LIMANY PROPRIETDRIPARTNERIEXECUTIVE YIN N 1 A E.L.EACH ACCIDENT $1 000,000 •_ <br /> OFFICERWEMBER EXCLUDED? EL DISEASE-EA EMPLOYE S 1 D00,000 <br /> (Mandatory In NH} - <br /> If yyea,deacride under EL DISEASE-POLICY IT $1 000 Doo <br /> DESCRIPTION OF OPERATIONS below <br /> F Employee Theft UC211 B4fi0519 21812019 21812020 Limll ;50,000 <br /> OpSCRIPTION OF OPERATIONS LOCATI DNS}VEHICLES (Atiach ACORD 101,Additional Remarks scheduie,if more space Ts regylrod) <br /> "Policles shown are subject to terms,conditions,exclusions,subllmits and deductibles not listed on this certificate. We recommend that requests for pCfiCy <br /> copies be directed to the Named Insured shown above,* <br /> Work Camp Policy #UBON2530781951 K-Covers the following States-CT,GA,,IL,MA, NJ,NY,NO,OK <br /> Work Comp Policy# U139Me461691951 R -Covers the follawing 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 /> Qrange County Department of Social Services <br /> 113 Maya Street AUTHORIZED R£ E5 ENYATIVE <br /> HIIlsborough NC 27278 <br /> 19911-2010 ACORD CORPORATION. At;rights reserved. <br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD <br />