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Docusign Envelope ID: 1 B31 C574-E288-4D4D-89A5-26EFE31 EFCF7 <br /> ACaR�� CERTIFICATE OF LIABILITY INSURANCE r ATE(MM/DDNYYY) <br /> 06/16/2025 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br /> HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE <br /> AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE <br /> ISSUING INSURER(S), AUTHORIZED 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 <br /> be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an <br /> endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> NAME:Trust Risk Management Services,Inc <br /> Trust Risk Management Services, Inc. doing business in NC PHONE FAX <br /> as Potomac Risk Management Services, Inc. (A/C, Ext):877.637.9700 (A/C,No):877.251.5111 <br /> 1791 Paysphere Circle ADDRESS:info@trustrms.com <br /> Chicago, IL 60674 INSURERS AFFORDING COVERAGE NAIC# <br /> INSURER A:ACE American Insurance Company 22667 <br /> INSURED INSURER B: <br /> Dr. Kristy L Matala INSURERC: <br /> 7633 Wilderness Rd <br /> Raleigh, NC 27613-1628 INSURERD: <br /> INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 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 <br /> PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT <br /> TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT <br /> TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR ADDL SUBR POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> CLAIMS MADE ❑OCCUR DAMAGE TO RENTED $ <br /> PREMISES(Ea occurrence) <br /> MED EXP(Any one person) $ <br /> PERSONAL&ADV INJURY $ <br /> n,OTHER: <br /> L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY ❑PRO- ❑LOC <br /> ECTPRODUCTS—COMP/OP AGG $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> Ea accident <br /> ANY AUTO BODILY INJURY(Per Person) $ <br /> ALL OWNED SCHEDULED $ <br /> AUTOS AUTOS BODILY INJURY(Per accident <br /> HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS (Per accident <br /> UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ <br /> WORKERS COMPENSATION PER STATUTE EORH $ <br /> AND EMPLOYERS LIABILITY Y/N <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ <br /> (Mandatory in NH) <br /> If yes,describe under E.L.DISEASE-POLICY LIMIT $ <br /> DESCRIPTION OF OPERATIONS below <br /> Psychologist's Professional Liability 58G26405865 09/29/2024 09/29/2025 Each Incident $1,000,000 <br /> A Retroactive Date 09/29/2014 Annual $3,000,000 <br /> Aggregate <br /> DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br /> Orange County, NC BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE <br /> 300 West Tryon St, PO BOX 8181 DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Hillsborough, NC 27278 <br /> AUTHORIZED REPRESENTATIVE <br /> ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />