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DocuSign Envelope ID: BE69DOF4-65F9-4511-85C7-BCBB1 0605A1 1 <br /> �• Tti� A4TL;MM.U[uYYYYF <br /> Rv�_AL CERTIFICATE OF UMILITY INSURANCE <br /> T HIIS CETITIF11CATE IS ISSUED AS A MA7'rIER INFOFMATION ONLY AND CONFERS NO RIGHTS UPON T14E CERTIFICATE HOLDER-THIS <br /> CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW- THIS CERTF"TE OF INSURANCE DOES NOT CONSTITUTE ACONTRACT BETWEEN THE FSSIIIhlG IN$UP.El%5).AUTHORiZIED <br /> R EPREuIENTAT1YE OR PRCOUCER,AND THE CERTIFICATE TrIOLDER- <br /> IMPORTAN{ If the ceffil5Date holder is an ADDrfIOFJ:AL INSURED,Use pDlicy{ies)nm st have ADDITIONAL INSURED prpvrtipog or be C;jjdc eEd <br /> If SUBROGAT'>i0N IS WANED.Sub oct to Ilso UVMS and conditions of trio policy,certain polidrs may require an endarsemenL A statement on <br /> Viih rertificata does not confer rights 1n Use cerd icaW holder In lieu of such endorsement(s)- <br /> PROMMER c❑NTAcT Diane H yv-au <br /> NAME: <br /> Buskm s InsLerers of CarolinaE (319)OG84611 FAX ( 19)466-8999 <br /> 601 tA4'ICw)F} ¢fib,$U0k,250 lDOE RESS.' ea dnadearu@b less-kwxers-com <br /> PO Box 2EW _ IHMPEFNSp AFFORDIWG COVERAGE NAIL a <br /> Chapel Fii9 NC 27515 IN5URERA: USLI 25995 <br /> Ir;94REP INSURFR 6: Gujrd in5lirfflK0 0281 <br /> LirAmv-rang Youth Lnf_ INEW R c: United States Liabdrty Insurance Company 25995 <br /> 925-ANath Esics Or IwkwFa a <br /> 114SU2ERE- <br /> Chape-I Hill NO 77514 INSUREgF F; <br /> COVERAGES CERTIFICATE NUMBER: CL20GOD2 93 REVISION NUMBER: <br /> TJ JIS 1$TO CEFMIF4'TI LOT TI JE POLICIr5 Cr WMIRMC;F L I TD BELOW HAVE BEEN ISSUED TO THE.INSURED XAMEL)ABOVE rtr THL r'CxeI y Pmici6 <br /> MDICATED. NOT4trITHSTANDNG ANY RLOUIRLMENT,TrRM OR CONEH1PDN OF MY CON 1KAe1 OM 0I HER LIOCUMENr WIYH KLsptcf 10 wKGH 1His <br /> C:ERf IFICATE MAY BE MSUED OR MAY PERTAIN,YHt INSURANCE AFFORDEDSY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTFIETERhc& <br /> EXCLUStONSAm WNOITKW43 OF SUCH POLICIES.LWIITSSHOWN MAY HAVE BEEN KEOCED BY PALD CLAJMS. <br /> INSR fuQR Pq4 FFF PRA 1E <br /> I-Tit TTJ'r Of IrltCURAWK IN68 I W4O I POLICY NWADER LIMITS <br /> G❑MMMCL4L GBIERALLWaIfrY C}CHOOCUfiRENCE f 1,U(X1,[F(}0 <br /> i;LAIM5 hI8Dr �S}C{:SJR PPEKL`YS Ca arc+sienor f 1�'S�� <br /> MFDFXPf0nrrubf-Aw,I $ CI{x} <br /> A NPP15M9542 (1710 112 0 2 1) p7.41V2021 PERSONALavUV IN.IuRr I 1,p00,040 <br /> OFNI AC'C;RrfaArr:IUIr a.F+PI IC-9 F+rR• rFJNFRAL ACX9WCALTF ; OQ9.04U <br /> POLICY LCIC PRODUUn-COPANOPAGG S 7,[ICkJ,Qf10 <br /> OTHER PL1m&Mokstatkm s 25,ODD <br /> Aur010311LE LUMURY COI{GNCD MINGLE IJW S 1.0%.000 <br /> ANYAITO DDnILY MJUFUWf p�) i <br /> A OrrMED SCHDIJULED DCUILY ra.WRY fP*p&UM a At S <br /> AIJM�ONLY ALr1G6 <br /> FNH.M NOr OYMED EFL7Y LV5kL5UL <br /> Au'IOs OrfY A"'fOC:CM,LY Tc � <br /> S <br /> UNOR6-LALUU! C} -R EhCN0=PRRENU $ <br /> FXEFSE LIAS CLAW&})AIC AcrvFf AW S <br /> rwD I I Rr-T TION 5 $ <br /> W090-R5 GUMPE SAY1014 3'JR {YTFL <br /> AWD ENFLDYE3?- LJABrLJrY STATUTE £R <br /> Y 1 N 100.000 <br /> aNVF+R{;F�FtICTpr�iAt{T}aEp�f{ECUTrwE E.LEnc�,AcciccNr � <br /> 8OFEICEFUME11 RFR E-XCJ-UDED7 ti` WA <br /> F��LIYf:172728 U71U1r'2J]2D {77�01f2a27 <br /> pVl.nd�er.ry fn lArl FI WISER-SF-Fn F'M'Er}►EF. L 100.00Q <br /> Ir 4cs,Uoscrft unfW <br /> DESCRIPTION CK OPLPAM0NS below C L DISSD%St-POLICY LIMIT 4 <br /> Ornci❑ra cJirwx rs Eao Occurerce 57,40UAU� <br /> c N1]015M&t 3C1 0i illzow i17f01 mri A99 2Ie S3,o00,040 <br /> EESGR CN❑F❑PERAMON51 LOCATONS!VEFIICLES fAC❑RD 101.Atla 6"al Ro da SaN dulo.may bo aM it m r4 ipa L,rrr{u:acl4 <br /> CERTIFICATE EIOLDER CANCELLATION <br /> SHOU LID At"OF 711E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE i:xriRAr103f DA1 E THEREOF,NOVICE 4YILL BE OL:LIYEFrEID w <br /> Orange County Human Services Ar'CORDANCF.WrrHTHF POLICY PROVISMS. <br /> PC Box R11 <br /> AUTYIgRQ[r}RFPRF4FNTATI4F <br /> Fidl,hnrnugh NC 27275 +` <br /> Cc, ACCORD CORPORATION- All i1ghL5 Feserved. <br /> ACORD 25(201 Libl) The ACORD name and logo are registered marks or ACORD <br />