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ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?
<br />INSR ADDL SUBRLTR INSD WVD
<br />PRODUCER CONTACTNAME:
<br />FAXPHONE(A/C, No):(A/C, No, Ext):
<br />E-MAILADDRESS:
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)
<br />AUTOMOBILE LIABILITY
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />AUTHORIZED REPRESENTATIVE
<br />EACH OCCURRENCE $
<br />DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)
<br />MED EXP (Any one person) $
<br />PERSONAL & ADV INJURY $
<br />GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
<br />PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT
<br />OTHER: $
<br />COMBINED SINGLE LIMIT $(Ea accident)
<br />ANY AUTO BODILY INJURY (Per person) $
<br />OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
<br />HIRED NON-OWNED
<br />PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY
<br />(Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $
<br />PER OTH-STATUTE ER
<br />E.L. EACH ACCIDENT
<br />E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under
<br />E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />COMMERCIAL GENERAL LIABILITY
<br />Y / N
<br />N / A
<br />(Mandatory in NH)
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<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.
<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 />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br />CERTIFICATE HOLDER CANCELLATION
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)
<br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
<br />$
<br />$
<br />$
<br />$
<br />$
<br />The ACORD name and logo are registered marks of ACORD
<br />10/24/2024
<br />(410) 685-4625 (410) 685-3071
<br />29580
<br />Oxford House, Inc
<br />1010 Wayne Ave, Ste 300
<br />Silver Spring, MD 20910
<br />10166
<br />A 1,000,000
<br />X HHS 8530942 11/18/2023 12/31/2024
<br />500,000
<br />20,000
<br />1,000,000
<br />3,000,000
<br />3,000,000
<br />1,000,000A
<br />HHS 8530942 11/18/2023 12/31/2024
<br />3,000,000A
<br />HHS 8530942 11/18/2023 12/31/2024 3,000,000
<br />0
<br />B
<br />AF WCP 100089169 04 1/15/2024 1/15/2025 1,000,000
<br />1,000,000
<br />1,000,000
<br />A Crime HHS 8530942 11/18/2023 250,000
<br />A Professional Liab. HHS 8530942 11/18/2023 12/31/2024 $1M OCC/$3M AGG.
<br />Orange County North Carolina is included as additional insured as respects to the General Liability portion of coverage for work performed by the named
<br />insured if required to be in a written executed contract with the named insured per the policy terms and conditions. 30 days’ notice of cancellation will be
<br />provided to the certificate holder in the event of cancellation or non-renewal, or 10 days’ notice in the event of cancellation for non-payment of premium.
<br />Orange County North Carolina
<br />300 West Tyron Street
<br />P.O Box 8181
<br />Hillsborough, NC 27278
<br />OXFOHOU-01 KWENGLER
<br />Maury, Donnelly & Parr, Inc.24 Commerce St.
<br />Baltimore, MD 21202
<br />Berkley Regional Insurance Company
<br />Accident Fund Insurance Company of America
<br />X
<br />12/31/2024
<br />X
<br />X
<br />X
<br />X X
<br />X
<br />X
<br />X
<br />Docusign Envelope ID: 9ADEFAD5-C106-45CE-909F-ED02DFA16A16
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