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--DocuSign Envelope ID: DCOCOA1 D-1 C9B-41 B9-9927-4B65B9A4A5C4 <br /> a o10/ <br /> CERTIFICATE OF LIABILITY INSURANCE DATE=(MW0DtYYyY) <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 have ADDITIONAL INSURED provisions or <br /> be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an <br /> endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> . PRODUCER CONTACT <br /> NAME:Trust Risk Management Services,Inc <br /> PHONE FAA <br /> Trust Risk Management Services, Inc.doing business in NC AIC,No,Ext•877,637.9700 INC,NO);877.261.6111 <br /> as Potomac Risk Management Services, Inc. EMAIL <br /> 1791 Paysphere Circle ADDRESS:IMo eirme,Gom <br /> Chicago,IL 60674 <br /> INSURERS.AFFORDING COVERAGE NAIC#INSURER A:AGE American Insurance Company 21667 <br /> INSURED INSURER B: <br /> Mareah C Steketee INSURERC: <br /> 100 Europa Dr Ste 260 INSURERD: <br /> Chapel Hill, NC 27517-2394 INSURERE. <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 <br /> PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT <br /> TO WHICH THIS CERTIFICATE MAY BE.ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT <br /> TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR ADD SU8 POLICY EFF POUCYEXP <br /> LTR TYPE OF INSURANCE INSR NND POLICY NUMBER (MMIDOIYYYY) (Mwoor YYY) LIMITS <br /> EACH OCCURRENCE <br /> COMMERCIAL GENERAL LIABILITY <br /> $ <br /> DAMAGE TO RENTED S <br /> CLAIMS MADE ❑OCCUR PREMISES Ea occurrence) <br /> MED EXP(Any one person). S <br /> 5 <br /> PERSONAL 8 ADV INJURY <br /> GEN'L AGGREGATE.LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> PRO- 5 <br /> PRODUCTS-COMPLOP AGG <br /> POLICY ❑JECT ❑LOC <br /> OTHER: <br /> COMBINED SINGLE LIMIT S <br /> AUTOMOBILE LIABILITY Eascddent <br /> ANY BODILY INJURY(Per Person) $ <br /> ALL OWNED SCHEDULED BODILY.INJURY(Per accident $ <br /> AUTOS AUTOS S <br /> NON-OWNED PROPERTY DAMAGE <br /> HIRED AUTOS AUTOS Per accident <br /> 5 <br /> UMBRELLA LIAR- OCCUR EACH OCCURRENCE S <br /> EXCESS UAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ <br /> PER. OTH- g <br /> WORKERS COMPENSATION STATUTE ER <br /> AND EMPLOYERS LIABILITY y I N EL.EACH ACCIDENT S <br /> ANY PROPRIETOR/PARTNERIJIXECUTIVE N f A $ <br /> OFFICERIMEMBER EXCLUDED? E.L DISEASE-EA EMPLOYE <br /> (Mandatory <br /> yestldeeatie In Nnder E.L.DISEA5E-POLICY LIMIT 5 <br /> DESCRIPTION OF OPERATIONS WOW <br /> Psychologist's Professional Liability 78G22448663 08/01/2020 08/01/2021 Each Incident <br /> F$4,000,000 <br /> 000,000 <br /> ARetroactive Date 02/08/2002 Ann A ua DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br /> Orange County Government BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE <br /> PO BOX 8181 DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Hllisborough, NC 27278 AUTHORIZED REPRESENTATIVE <br /> ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />