2021-114-E Social Svc-Matala Psychological Services evaluation services

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DocuSign Envelope ID:OB9D9800-1906-43A7-8OF7-F2EBC1B3033F ® DATE(MM/DDIYYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE 09/04/2020 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME:Trust Risk Management Services,Inc PHONE FAX Trust Risk Management Services,Inc.doing business in NC as Potomac (A/C,No,Ext):877.637.9700 A/C,No:877.251.5111 Risk Management Services,Inc. EMAIL ADDRESS:inf 1791 Paysphere Circle INSURER S AFFORDING COVERAGE NAIC# Chicago,IL 60674 INSURER A:ACE American Insurance company 22667 INSURED INSURER B: Kristy Matala INSURER C: 7633 Wilderness Rd INSURER D: Raleigh, NC 27613 1628 INSURER E: INSURER F: 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 BEEN REDUCED BY PAID CLAIMS, INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIODIYYYY) (MM/DDNYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS MADE ❑OCCUR DAMAGES(TO RENTED $ PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY 1,0THER: L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- PRODUCTS—COMP/OP AGG $POLICY ❑JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per Person) $ ALL OWNED SCHEDULED $ AUTOS AUTOS BODILY INJURY(Per accident HIRED AUTOS NON-OWNEDPROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ - WORKERS COMPENSATION PER OTH- $ AND EMPLOYERS LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.LEACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ E.L.DISEASE-EA EMPLOYE $ (Mandatory in NH) If yes,describe under $ E.L.DISEASE-POLICY LIMI DESCRIPTION OF OPERATIONS below Psychologist's Professional 58G26405865 09/29/2020 09/29/2021 Each Incident $1,000,000 A Liability Annual $3,000,000 Retroactive Date:09/29/2014 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required): The policy provides defense up to the policy limits for any Claim upon which suit is brought for alleged sexual abuse or molestation until thereis a judgment or final adjudication adverse to any Insured,or an admission by any Insured accused of such behavior or act and it isestablished that such behavior caused,in whole or part,the injury claimed in such suit. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Orange County Government BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough NC 27278 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION.All rights reserved,