2021-597-E-Health-Planned Parenthood South Atlantic-Amendment to Outside Agency Agreemen

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Attachments P a g e 15 o f 20 h)Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency’s FY 2019-20 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. i)Certificate of Liability Insurance A copy of the agency’s current certificate, from the agency’s insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker’s Compensation compliance, include a statement explaining why, with the agency’s application materials. NOTE: Proof of insurance is not required at the time of application submission. If your agency is approved for funding, documentation of insurance must be provided to the jurisdiction awarding the funding when the contract is awarded. The insurance certificate should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 – June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. NOTE: Upon request, insurance requirements may be reviewed on a case by case basis by the Town or County. Please contact the staff identified on the Submission Requirements on Page 2 if you have questions or would like to request a review of your insurance requirements. Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Compensation1 Limits for Coverage A - Statutory State NC, for each employee Limits for Coverage B - Employers Liability of: $1 million Each Occurrence $1,000,000 BID2 limit Limits for Coverage A - Statutory State NC, for each employee Limits for Coverage B - Employers Liability of: $100,000 Each Occurrence $100,000 BID for each employee $500,000 BID limit Limits for Coverage A - Statutory State NC, for each employee Limits for Coverage B - Employers Liability of: $500,000 each accident, $500,000 BID for each employee $500,000 for BID limit Commercial General Liability $100,000 Property Damage Liability $1 Million Bodily Injury and Property Damage Limit $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate Automobile Liability Not Applicable $1 million Each Occurrence *Only required for agencies doing travel as part of the agreement with the Town. $1 million Each Occurrence Professional Liability Not Applicable $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate Sexual Abuse & Molestation Not Applicable $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BADocuSign Envelope ID: 01146459-28D7-41C1-ADA0-09401D3877AD