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<br />P.O. Box 8181 * Hillsborough, North Carolina 27278 <br />Telephone: 919 245-2626 <br /> List of Board of Directors (if applicable) <br />Provide the following information about each board of director’s member: name, telephone <br />number, and address, of each member and the list must identify the principal officers of the <br />governing body, and length of term. Please feel free to use the template provided in Table 2 of <br />the appendix or your own format. <br /> <br /> Solid Waste Program Fee (SWPF) Verification <br />This fee finances Orange County's recycling and waste reduction program. Submit either a.) <br />proof of payment of the applicant organization’s FY 2019-20 Solid Waste Program Fee, OR b.) a <br />statement on the applicant organization’s letterhead indicating exemption and specify the <br />person(s), business, etc. that is responsible for paying this fee. <br /> <br /> Certificate of Liability Insurance <br />A copy of the applicant organization’s current certificate, from the organization’s insurance <br />carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If <br />exempt from Worker’s Compensation compliance, include a statement explaining why, with the <br />applicant organization’s application materials. <br /> <br />NOTE: Proof of insurance is not required at the time of application sub mission. If your agency <br />is approved for funding, documentation of insurance must be provided to the jurisdiction <br />awarding the funding when the contract is awarded. The insurance certificate should reflect the <br />funding jurisdiction as an additional insured party and certificate holder and provide coverage for <br />the duration of the funding period (two years, beginning as early as October 1, 2021). If proof of <br />insurance can only be written for one year, an update will be required for all ongoing projects. <br />Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, <br />cancellation or modification of any stipulated insurance coverage. <br /> <br />NOTE: Upon request, insurance requirements may be reviewed on a case by case basis by the <br />County. Please contact the staff identified on the Submission Requirements on Page 15 if you <br />have questions or would like to request a review of your insurance requirements. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />DocuSign Envelope ID: E86DD11C-7C3F-4DD6-97F0-CADB5D52D35A