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Holder Identifier : 7777777707070700077761616045571110767735324015474207762315770734132070670447047333220717141222253110107754041603775701077625200324155730734275551277653007234220152371130076727242035772000777777707000707007 7777777707070700073525677115456000727111016436402007664151570376476074673776020370550743733221712215507033372603026001070233263520631110713333634316210007132227253173001077756163351765540777777707000707007Certificate No :570094894245CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> 08/15/2022 <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If <br />SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this <br />certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />PRODUCER <br />Aon Risk Services Central, Inc. <br />Chicago IL Office <br />200 East Randolph <br />Chicago IL 60601 USA <br />PHONE(A/C. No. Ext): <br />E-MAILADDRESS: <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />(312) 381-1000 <br />INSURED 20303Great Northern Insurance Co.INSURER A: <br />12777Chubb Indemnity Insurance Co.INSURER B: <br />20281Federal Insurance CompanyINSURER C: <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />FAX(A/C. No.):(312) 381-7007 <br />CONTACTNAME: <br />FORVIS, LLP <br />Attn: Scott Henderson <br />910 East St. Louis Street <br />Suite 400 <br />Springfield MO 65806 USA <br />COVERAGES CERTIFICATE NUMBER:570094894245 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 PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.Limits shown are as requested <br />POLICY EXP (MM/DD/YYYY)POLICY EFF (MM/DD/YYYY)SUBRWVDINSR LTR ADDL INSD POLICY NUMBER TYPE OF INSURANCE LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS-MADE OCCUR <br />POLICY LOC <br />EACH OCCURRENCE <br />DAMAGE TO RENTED <br />PREMISES (Ea occurrence) <br />MED EXP (Any one person) <br />PERSONAL & ADV INJURY <br />GENERAL AGGREGATE <br />PRODUCTS - COMP/OP AGG <br />X <br />X <br />X <br />XX <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />$1,000,000 <br />$1,000,000 <br />$10,000 <br />$1,000,000 <br />$2,000,000 <br />Included <br />Blanket Additional Insured <br />A 09/30/2021 09/30/2022 <br />General Liability <br />35801735 <br />PRO- <br />JECT <br />OTHER: <br />AUTOMOBILE LIABILITY <br />ANY AUTO <br />OWNED <br />AUTOS ONLY <br />SCHEDULED <br /> AUTOS <br />HIRED AUTOS <br />ONLY <br />NON-OWNED <br />AUTOS ONLY <br />BODILY INJURY ( Per person) <br />PROPERTY DAMAGE <br />(Per accident)X X <br />BODILY INJURY (Per accident) <br />$1,000,000A09/30/2021 09/30/2022 <br />Auto <br />COMBINED SINGLE LIMIT <br />(Ea accident) <br />(21) 7498-28-67 <br />EXCESS LIAB <br />X OCCUR <br />CLAIMS-MADE AGGREGATE <br />EACH OCCURRENCE <br />DED <br />$5,000,000 <br />$5,000,000 <br />09/30/2021 <br />Umbrella <br />UMBRELLA LIABC 09/30/202279808657 <br />RETENTION <br />X <br />E.L. DISEASE-EA EMPLOYEE <br />E.L. DISEASE-POLICY LIMIT <br />E.L. EACH ACCIDENT $1,000,000 <br />X OTH-ER <br />PER STATUTEB09/30/2021 09/30/2022 <br />Workers Compensation <br />$1,000,000 <br />Y / N <br />(Mandatory in NH) <br />ANY PROPRIETOR / PARTNER / EXECUTIVE <br />OFFICER/MEMBER EXCLUDED?N / AY <br />WORKERS COMPENSATION AND <br />EMPLOYERS' LIABILITY <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />$1,000,000 <br />2271755811 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Certificate holder is listed as additional insured in regards to the General Liability, Auto and Umbrella coverage as required <br />by written contract. <br />CANCELLATIONCERTIFICATE HOLDER <br />AUTHORIZED REPRESENTATIVEOrange County Health Department <br />PO Box 8181 <br />Hillsborough, NC 27278 USA <br />ACORD 25 (2016/03) <br />©1988-2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE <br />POLICY PROVISIONS. <br />DocuSign Envelope ID: 55495011-1414-4543-B06A-69B9D4DEAE05