HomeMy WebLinkAbout2013-423 Finance - Orange County Literacy Council Outside Agency $12,000 is�4-�✓`c �
2013-14 OUTSIDE AGENCY PERFORMANCE AGREEMENT
This Agreement, made and entered into the first day of July 2013, by and between the
County of Orange, a political subdivision of the State of North Carolina, 200 South
Cameron Street,Hillsborough,North Carolina, 27278, ("County") and OC Literacy Council,
a not-for-profit corporation, located at 200 N. Greensboro St., Suite C-2, NC 27510
("Provider").
WITNESSETH:
WHEREAS,it is in the interests of the County that said program be assisted by the County
and thereby enhance its availability to residents of the County, and said program addresses
an important community human services need,as identified by the Board of Commissioners;
NOW, THEREFORE, in consideration of the above and the mutual covenants and
conditions hereafter set forth,the County and OC Literary Council agree as follows:
1. Term of the Agreement. The term of this Agreement shall be a program year
beginning July 1,2013 to June 30,2014.
2. Scope of Services.
a. Provider will provide services, as outlined in the attached Outside Agency
Funding Application Scope of Services and any amendments or revision
thereto which is attached as Exhibit "A" and incorporated by reference, to
the residents of Orange County. The Scope of Services may be different
from the original application based on County appropriation; however, any
revisions or amendments to this Agreement must be approved in writing by
the County and attached to this Agreement.
b. The Provider shall be solely responsible for the means, methods, techniques,
sequence, safety program and procedures necessary to properly and fully
complete the work set forth in the Scope of Services.
3. Funding.
a. The County agrees to appropriate for the provision of services described in
Exhibit A, Scope of Services and more particularly described in the Program
Budget,the maximum sum of$12,000.
b. All funds appropriated shall be used for purposes described in Exhibit A.
Any funds not used for the purposes stated shall be returned to the County.
Any substantive changes in the use of funds must be authorized in writing by
the County prior to any expenditure of the funds by the Provider. If the
funds are expended not in accordance with the Scope of Services, at the
(OC Literacy Council)
Orange County Outside Agency Performance Agrzement
Page 1 of 8
discretion of the County the Provider may be required to repay the funds to
the County.
c. The County's obligation to make each payment is contingent upon receipt of
Progress Reports and satisfactory progress toward completion of
performance measures and accounting of expenditures as detailed in the
attached Scope of Services.
d. The Provider shall be paid in four equal installments in the amount of
$3,000,contingent upon receipt of the request for reimbursement and related
supporting documentation. The first installment shall be paid no later than
August 30 of the Program year only if execution of this Outside Agency
Performance Agreement by both the County and the Provider is completed
by August 15 of the program year; the remaining installments shall be
disbursed on January 31,April 30 and July 23 of the program year and upon
satisfactory completion of(c) and the information included in this paragraph.
e. Once Provider has satisfied its obligations as provided in (c) and (d) above,
payment will be made 30 days after receipt of the Progress Report and
Request for Reimbursement or 30 days after due date of Progress Report
whichever is later.
f. The County is not obligated to provide any other support to Provider in this
or in succeeding fiscal years.
4. Agency Reporting.
a. Provider will provide Orange County a report that includes a fiscal report,
updates on 2013-14 performance measures and objectives as provided in
Scope of Services. Progress Report dates are:July 1 —December 31;January
1 —March 31 and April 1 -June 30. Reports are due on January 15,April 15,
and July 8 of the program year.
b. Reports shall be forwarded to the Orange County Manager's Office.
c. Provider agrees to allow the County to inspect its financial books and
records, which document costs of those services, upon reasonable notice
during normal working hours.
5. Termination.
a. In the event of any of the circumstances set forth below (hereinafter referred
to as "default"), the County may immediately terminate this Agreement, in
whole or in part, and from time to time. Notice of termination must be in
writing, state the reason or reasons for the termination, and specify the
effective date of the termination:
(OC Literacy Council)
Orange County Outride Agency Performance Agreement
Page 2 of 8
i. In the event that Provider shall cease to exist as an organization or
shall enter bankruptcy proceedings,be declared insolvent,or liquidate
all or substantially all of its assets, or significantly reduce its services
or accessibility to Orange County residents during the term of this
Agreement;or
ii. In the event that Provider shall fail to render a satisfactory
accounting as provided section 4 above, the County may terminate
this Agreement and Provider shall return all payments already made
to it by the County for services which have not been provided or for
which no satisfactory accounting has been rendered;or
iii. In the event of any fraudulent representation by the Provider in an
invoice or other verification required to obtain payment under this
Agreement or other dishonesty on a material matter relating to the
performance of services under this Agreement.
iv. Nonperformance,incomplete service or performance,or failure to
satisfactorily perform any part of the work identified in the Scope of
Services or to comply with any provision of this Agreement,as
determined by the County in its sole discretion.
v. Failure to adhere to the terms of applicable county, state or federal
laws,regulations,or stated public policy.
b. In the event of default by the Provider,the county may elect to terminate this
Agreement, in whole or in part and/or require the Provider to repay the
funds within ten (10) business days from written notice of default. The
County may (but shall not be required to) grant the Provider an opportunity
to cure the default without termination of this Agreement. This clause shall
not be interpreted to limit the County's remedies in law or in equity.
c. Notwithstanding the foregoing, either party may terminate the agreement at
any time without penalty; provided that written notice of such termination is
furnished to the other party at least 30 days prior to termination. In the
event of such termination, any payment due shall be prorated to the date of
termination and any unused funds shall be returned to the County within 10
days of termination.
d. Any termination of this Agreement for default under this section that is later
deemed to be unjustified shall be deemed a termination for convenience.
6. Insurance.
a. General Requirements. The Provider shall purchase and maintain,during the
period of performance of this Agreement,insurance:
(OC Literacy Council)
Orange County Outside Agency Perfomance A&rement
Page 3 of 8
i. Worker's Compensation. For protection from claims under workers'
or workmen's compensation acts;
ii. Comprehensive General Liability Insurance covering claims arising
out of or relating to bodily injury,including bodily injury, sickness,
disease or death of any of the Consultant's employees or any other
person and to real and personal property including loss of use
resulting thereof;
iii. Comprehensive Automobile Liability Insurance,including hired and
non-owned vehicles,if any,covering personal injury or death,and
property damage;and
iv. Professional Liability Insurance,covering personal injury,bodily
injury and property damage and claims arising out of or related to the
performance under this Agreement by the Consultant or his agents,
consultants and employees.
b. Limits of Coverage: Minimum limits of insurance coverage shall be as
follows:
INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE
• Worker's Compensation Limits for Coverage A- Statutory State
NC&Coverage B - Employers Liability
$500,000 each accident,disease policy
limit and disease each employee
• Commercial General $1,000,000 Each Occurrence
Liability $2,000,000 Aggregate
• Automobile Liability $500,000 Combined Single Limit
• Professional Liability $1,000,000 Each Occurrence
$2,000,000 Aggregate
c. All insurance policies (with the exception of Worker's Compensation and
Professional Liability) required under this Agreement shall name the County
as an additional insured party and as a certificate holder. Evidence of such
insurance and all correspondence shall be sent to:
Orange County Risk Manager
Post Office Box 8181
Hillsborough,NC 27278
d. Nothing in this section is intended to affect or abrogate the County's
sovereign immunity defenses.
(OC literacy Council)
Orange County Outside Agency Performance Agreement
Page 4 of 8
7. Relationship of the Parties. Provider is an independent contractor of the County.
Provider represents that they has or will secure, at his own expense, all personnel
required in performing the services under this Agreement. Such personnel shall not
be employees or have any contractual relationship with the County. All personnel
engaged in work under this Agreement shall be fully qualified and shall be authorized
and permitted under federal, state and local law to perform such services.
8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all
laws, ordinances, orders and regulations of the federal, state or local governments, as
well as their respective departments, commissions, boards, and officers,which are in
effect at the time of execution of this Agreement or are adopted at any time
following execution of this agreement.
9. Subcontract. The County and Provider deem the services provided under this
Agreement to be personal in nature and Provider may not subcontract any rights or
duties under this Agreement to any other party without prior written consent from
the County.
10. Assignment. The Provider shall not assign this Agreement, including the rights to
payment,to any other party without the prior written consent of the County.
11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the
County, for all loss, liability, claims or expense (including reasonable attorney's fees)
arising from bodily injury, including death or property damage, to any person or
persons caused in whole or in part by the negligence or willful misconduct of the
Provider, except to the extent same are caused by the negligence or willful
misconduct of the County. It is the intent of this section to require Provider to
indemnify the County to the extent permitted under North Carolina law. Nothing in
this section is intended to affect or abrogate the County's sovereign immunity
defenses.
12. Non-Appropriation. This Agreement is subject to the availability of funds to
purchase the specified services and may be terminated at any time if such funds
become unavailable.
13. Non-Discrimination. Provider agrees as part of consideration of the granting of
funds by Orange County the parties hereto for themselves, their agents, officials,
employees and servants agree not to discriminate in any manner of these basis of
race,color,gender, national origin, age,handicap,religion, sexual orientation, familial
status or veterans status with reference to any activities carried out by the grantee,no
matter how remote. The parties hereto further agree in all respects to conform to
the provision and intent of Orange County Civil Rights Ordinance, as
amended. This provision is enforced by action for specific performance, injunctive
relief, or other remedy as by law provided; this provision shall be binding on the
grantees, the successors and assigns of the parties hereto with reference to the above
subject manner.
(OC Literacy Council)
Orange County Outside Agency Performance Agreement
Page 5 of 8
14. Living Wage. Orange County is committed to providing its employees with a living
wage and encourages agencies if funds to pursue the same goal. The County's living
wage is $10.97 per hour. To the extent possible, Orange County recommends that
OC Literacy Council provide a living wage to its employees.
15. Notice. The Parties hereto agree and understand that written notice, mailed or
delivered, to the last known address shall constitute sufficient notice to the County
and the Provider. All notices required and/or made pursuant to this Agreement to
be given to the County and the Provides shall be in writing and mailed to the party
addressed as follows:
County: County Manager's Office Provider: <AOC�s Y1
Orange County X1:)4-e_C--=2
Post Office Box 8181 C—'c�.✓�l
Hillsborough,NC 27278 Z-75
16. Entire Agreement. This Agreement, including any referenced attachments,
constitutes the entire Agreement between the parties and shall supersede, replace or
nullify any and all prior Agreements of understandings;written or oral,relating to the
matters set forth herein,and any such prior Agreements or understandings shall have
no force or affect whatsoever on this Agreement. The County and Provider have
read this Agreement and agree to be bound by all of its terms, and further agree that
this Agreement constitutes the complete and exclusive statement of the Agreement
between the County and Provider.
17. Severability. All clauses found herein shall act independently of each other. If a
clause is found to be illegal or unenforceable, it shall have no effect on the other
provisions of this Agreement. It is understood by the parties hereto that if any part,
term or provision of this Agreement is by the Courts held to be illegal or in conflict
with any laws of the State of North Carolina or the United States, the validity of the
remaining portions or provisions shall not be affected, and the rights and obligations
of the parties shall be construed and enforced as if the Agreement did not contain
the particular part,term or provision held to be invalid.
18. Governing Law. The laws of the State of North Carolina shall govern all aspects of
this Agreement. In the event that it is necessary for either party to initiate legal
action regarding this Agreement, venue shall lie in Orange County, North Carolina.
The parties hereby waive their right to trial by jury in any action,proceeding or claim,
arising out of this Agreement,which may be brought by either of the parties.
[SIGNATURES ON FOLLOWING PAGE]
(OC Literacy Council)
Orange County Outside Agency Performance A.-ement
Page 6 of 8
IN WITNESS WHEREOF, the Orange County and the Provider have signed this
Agreement,effective on the last date this Agreement is signed by both parties as indicated by
the dates set forth under signatures below.
For and on behalfoftbe Provider
Z
Insert Name Date
For o eh l of ange Co G rnment
L
b .�
County anag r Date
Rtte o form and legal sufficiency
oore, ta ll Attorney Date
Approved as to technical content:
This instrument has been pre-audited in the manner required by the Local Government
Budget and Fiscal Control Act
(r( A J/j,'-.
Clarence Grier,Assistant County Manager/ Date
Chief Financial Officer
(OC Literacy Council)
Orange County Outride Agency Performance Agreement
Page 7 of 8
ATTACHMENT"A"
Orange County Certifications—FY 2013 - 14
Outside Agency Performance Agreement
Chief Contact,Administrators,Chief Executive Officer and Chief Financial Officer
I certify that I have provided a list of the chief contact, administrators, chief executive
officer and chief financial officer for my agency with this Agreement and that I will keep
it current to the County of Orange. The list should be in writing with the name,title,
residential address;phone and email address and if possible, fax number.
Officers and Board of Directors
I certify that I have provided a current list of the Officers and Board of Directors with this
Agreement and that we will continue to update the list as changes occur. The list should
be in writing,with the name,physical address,mailing address and if possible,phone, fax
and email address.
Budget Submission
I certify that I have provided a budget for the period to be covered by funding Orange
County, and that any substantive changes made to this budget have been in advance
authorized in writing by Orange County.
Annual Financial Review
I certify that I have provided a copy of the latest annual Financial Review for our agency
and the budget adopted by the agency for the fiscal years encompassing this Agreement.
If not,please explain on a separate sheet of paper.
Alignment with Organization's Mission
I certify that the programs and services for which this funding is requested align with the
mission of the organization.
Intended Purpose
I certify that the funds provided to the agency under the terms of this Agreement will be
used for a public purpose and shall only be used for the purposes intended and any money
not used for those purposes will be promptly returned to Orange County.
Certified by: 1 Title: -/"Date:
(OC Literacy Council)
Orange County Outride Agency Performance Agement
Page 8of8
Exhibit A—Scope of Services—Fiscal Year 2013-14
Orange County Outside Agency Performance Agreement Certification
Funded Amount: $ 12,000
Agency: Orange County Literacy Council
Agency Mission: We provide free, individualized literacy instruction to anyone living or working in Orange
County,who would like to improve their reading,writing, basic math, computer or English
lanouaae skills_ p
Program: Adult Literacy
Purpose: OCLC's Adult Literacy Program provides individualized and small group instruction to adult
learners who want to improve their reading,writing, basic math, basic computer, English
language and GED preparation skills.
Outcomes: By June 30, 2014, 60%of all students entering the program will become fulltime students
(12 hours or more)and of those fulltime students, 60%who are post-tested will make
measurable progress on a federally recognized standardized test.
Budget for Orange County Funding:
Category Amount Expense Description
Operations $ 12,000 Rent-direct expenses for rent, calculated at FY2012 audited rate of 90%direct
Certified
Alice Title: Date:Denson Executive Director 9/16/2013
t4uto-Owners Page 1 54643 (01-90)
Issued 10-04-2012
(MUTUAL) INSURANCE COMPANY BUSINESSOWNERS POLICY DECLARATIONS
6101 ANACAPRI BLVD. , LANSING, MI 48917-3999
Renewal Effective 11-20-2012
AGENCY HIGH $ RUBISH INSURANCE AGENCY
15-0936-00 MKT TERR 050 (919) 913-1144 POLICY NUMBER 91-159-372-01
INSURED ORANGE COUNTY LITERACY COUNCIL INC Company Use 35-57-NC-9311
Company POLICY TERM
ADDRESS 200 N GREENSBORO ST STE C2 Bill 12:01 a.m. 12:01 a.m.
CARRBORO NC 27510-1833 to
11-20-2012 11-20-2013
In consideration of payment of the premium shorn below, this policy is renewed. Please attach this
Declarations and attachments to your policy. If you have any questions, please consult with your agent.
ENTITY: Corporation
PROPERTY COVERAGES - ALL DESCRIBED LOCATIONS DED LIMITS PREMIUM
Special Coverage Form
TERRORISM - CERTIFIED ACTS 9.61
BUSINESS LIABILITY PROTECTION LIMITS PREMIUM
COVERAGES
Aggregate Limit $2,000,000 Included
(Other than Products-Completed Operations)
Products-Completed Operations Aggregate 11000,000 Included
Liability and Medical Expense 11000,000 Included
Medical Expense - Per Person 51000 Included
Personal Injury Included Included
Tenants Fire Legal - Any One Fire 50,000 Included
Hired Auto $ Non-Owned Auto Liability 11000,000 $31.78
TERRORISM - CERTIFIED ACTS .64
FORMS THAT APPLY TO ALL LOCATIONS: 54510 (08-09) BP0002 (01-87) BP0006 (01-87)
BP0009 (01-87) 54679 (06-92) 54709 (04-10) 54098 (05-07) 54319 (07-06)
54867 (03-08) 54656 (08-91) 54088 (09-09) 54663 (01-03)
AUTO-OWNERS (MUTUAL) INS. CO. Page 2 54643 (01-90)Issued 10-04-2012
AGENCY HIGH & RUBISH INSURANCE AGENCY Company POLICY NUMBER 91-159-372-01
15-0936-00 MKT TERR 050 Bill Company Use 35-57-NC-9311
INSURED ORANGE COUNTY LITERACY COUNCIL INC Term 11-20-2012 to 11-20-2013
LOCATION 001
LOCATION: 200 N GREENSBORO ST STE C2 CARRBORO NC 27510-1833
COVERAGES DED LIMITS PREMIUM
Addl Insured - Managers or Lessors of Premises Included $22.07
Addl Insured - Controlling Interest Included 22.07
TERRORISM
CERTIFIED ACTS SEE FORM(S) 59350, 54309, 59390 3.36
ADDITIONAL FORMS FOR THIS LOCATION: BP0007 (01-90) BP0116 (03-87) IL0162 (04-90)
IL0269 (10-94) 54094 (03-07) 54238 (12-01) 54244 (05-07) 54309 (07-08)
54605 (11-88) 54661 (08-91) 59350 (01-08)
LOC 001 BLDG 0001
COVERAGES DED LIMITS PREMIUM
Business Personal Property - REPL. COST $500 $26,650 $119.46
Adjusted Value Factor 0.0370
Business Income And Extra Expense 12 Months Included
Limitation of Coverage for Fungi, Mold, See Form Included
Dry Rot, Wet Rot and Bacteria
Equipment Breakdown 500 See Form 4.50
ADDITIONAL FORMS FOR THIS BUILDING: 54841 (10-09) 54701 (08-94) 54703 (08-94)
BP1203 (06-89)
SECURED INTERESTED PARTIES: See Attached Schedule
ItAut0-Ott hers Page 3 54643 (61-90)
Issued 10-04-2012
(MUTUAL) INSURANCE COMPANY BUSINESSOWNERS POLICY DECLARATIONS
6101 ANACAPRI BLVD., LANSING, MI 48917-3999
AGENCY HIGH & RUBISH INSURANCE AGENCY Renewal Effective 11-20-2012
15-0936-00 MKT TERR 050 (919) 913-1144 POLICY NUMBER 91-159-372-01
INSURED ORANGE COUNTY LITERACY COUNCIL INC Company Use 35-57-NC-9311
Company o POLICY TERM
ADDRESS 200 N GREENSBORO ST STE C2 Bill 12:01 a.m. 12:01 a.m.
CARRBORO NC 27510-1833 to
11-20-2012 11-20-2013
In consideration of payment of the premium shown below, this policy is renewed. Please attach this
Declarations and attachments to your policy. If you have any questions, please consult with your agent.
RATING INFORMATION
Occupancy: Office Not Otherwise Classified Tenant Occupied
Class Code: 65121 Const: Non-Combustible, Sprinklered
Program: Office Protection Class: 03
Liability Rate Number: 00 Territory: 010 Orange County
Burglary Rate Group: 00 Inside City Limits
Construction Year: 1965
TERM
TOTAL ANNUAL PREMIUM $204.49
MINIMUM PREMIUM EQUIPMENT BREAKDOWN ADJUSTMENT $30.50
MINIMUM PREMIUM ADJUSTMENT $169.62
TOTAL POLICY PREMIUM $404.61
PAID IN FULL DISCOUNT -9.96
TOTAL POLICY PREMIUM IF PAID IN FULL $394.65
The Paid In Full Discount does not apply to fixed fees or statutory charges.
The Paid In Full Discount is based on favorable loss experience for the collective group
of policyholders who choose to pay their premiums in full directly to the company.
Paid In Full Discount is available.
Discount Applies for Affiliation with: CHAPEL HILL - CARRBORO CHAMBER OF COMMER
A 4% Cumulative Multi-Policy Discount applies. Supporting policies are marked with
an (X): Comm Umb( ) Comm Auto( ) WC(X) Life( ) Personal( ) Farm( ) .
Merit Rating Discount of 5% Applies
Pape 4 54643 (01-90)
AUTO-OWNERS (MUTUAL) INS. CO. Issued 10-04-2012
AGENCY HIGH 8: RUBISH INSURANCE AGENCY Company POLICY NUMBER 91-159-372-01
15-0936-00 MKT TERR 050 Bill Company Use 35-57-NC-9311
INSURED ORANGE COUNTY LITERACY COUNCIL INC Tern: 11-20-2012 to 11-20-2013
SECURED INTERESTED PARTIES AND/OR ADDITIONAL INTERESTED PARTIES
Lac 001 Bldg 0001 ,
OCE FINANCIAL SERVICES Loan: 200-5028065-000
5600 BROKEN SOUND BLVD NW
BOCA RATON FL 33487-3515
Interest: Loss Payable LEASED COPIER
Form: BP1203 PARAGRAPH A
SIP-ID: FL147731
r
Agency Code 15-0936-00 Policy Number 91-159-372-01
54701 (8-94)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - CONTROLLING INTEREST
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS POLICY
SCHEDULE*
Name of Person or Organization:
ORANGE COUNTY ATTN RISK MANAGER
PO BOX 8181
HILLSBOROUGH, NC 27278
The following is added to Paragraph C. WHO IS AN INSURED in the Businessowners Liability Coverage Form:
4. The person or organization shown in the Schedule or in the Declarations, but only for their liability arising out
Of
a. Their financial control of you; or
b. Premises they own, maintain or control while you lease or occupy those premises.
This insurance does not apply to structural alterations, new construction and demolition operations performed
by or for that person or organization.
The limit of liability for the additional insured are those specified in the written contract or agreement between the
Insured and the Person or Organization named above, not to exceed the limits provided in this policy. These limits
are inclusive of and not in addition to the limits of insurance shown in the Declarations.
*Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declara-
tions.
Includes copyrighted material of Insurance Services Office, Inc.,with its permission
Copyright, Insurance Services Office, Inc., 1985
Agency Code 15-0936-00 Policy Number 91-159-372-01 ;
54703(8-94)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - MANAGERS OR LESSORS
OF PREMISES
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS POLICY
SCHEDULE*
Designation of Premises (Part Leased to You):
200 N GREENSBORO ST STE C2
Name of Person or Organization(Additional Insured):
CARR MILL MALL LIMITED PARTNERSHIP
PO BOX 673
CARRBORO, NC 27510
Additional Premium:
A. The following is added to Paragraph C.WHO IS AN INSURED in the Businessowners Liability Coverage Form:
4. The person or organization shown in the Schedule is also an insured, but only with respect to liability aris-
ing out of the ownership, maintenance or use of that part of the premises leased to you and shown in the
Schedule.
B. The following exclusions are added:
This insurance does not apply to:
1. Any "occurrence" that takes place after you cease to be a tenant in the premises described in the Sched-
ule.
2. Structural alterations, new construction or demolition operations performed by or for the person or organi-
zation designated in the Schedule.
The limits of insurance for the additional insured are those specified in the written contract or agreement between
the insured and the person or organization named above, not to exceed the limits provided in this policy. These
limits are inclusive of and not in addition to the limits of insurance shown in the Declarations.
* Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declara-
tions.
Includes copyrighted material of Insurance Services Office,Inc.,with its permission
Copyright, Insurance Services Office, Inc., 1984, 1985
SCANNE D-
PAGE ED
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?
/]��� PAGE 1 D
,�utO-Qwners WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY
INSURANCE COMPANY 16144
6101 ANACAPRI BLVD. , LANSING, MI 48917-3999
INFORMATION PAGE -RENEWAL AGREEMENT RENEWAL EFF. 06-17-2013
AGENCY HIGH & RUBISH INSURANCE AGENCY
15-0936-00 PO BOX 3040 (919) 913-1144 POLICY NUMBER
CHAPEL HILL NC 27515 MKT TERR 050 041715 35022549
ITEM 1
INSURED ORANGE COUNTY LITERACY COUNCIL INC ITEM 2 POLICY PERIOD
COMPANY FROM 12:01 A.M. 06-17-2013
ADDRESS 200 N GREENSBORO ST STE C2 BILL TO 12:01 A.M. 06-17-2014
CARRBORO NC 27510-1833 AT THE INSURED'S
MAILING ADDRESS
INSURED IS - CORPORATION
OTHER WORK PLACES NOT SHOWN ABOVE:
ITEM 3 A. WORKERS' COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS'
COMPENSATION LAW OF THE STATES LISTED HERE: NC
B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE
LISTED IN ITEM 3. THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE:
BODILY INJURY BY ACCIDENT 8100,000 EACH ACCIDENT
BODILY INJURY BY DISEASE 8100,000 EACH EMPLOYEE
BODILY INJURY BY DISEASE 8500,000 POLICY LIMIT
C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY,
LISTED HERE: AL, AR, A2, CO, FL, GA, IA, ID, IL, IN, KS, KY, MI, MN, MO, NC, NE,
PA, SC, SD, TN, UT, VA & WI UNLESS ALREADY LISTED IN ITEM 3A.
ITEM 4 THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS RULES, CLASSIFICATIONS,
RATES AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION
AND CHANGE BY AUDIT.
CLASSIFICATIONS OF OPERATIONS PREMIUM BASIS RATES
ESTIMATED RATE ESTIMATED
CLASS TOTAL ANNUAL PER ANNUAL
CODE REMUNERATION 8100 PREMIUM
STATE OF NORTH CAROLINA
ID* 0010 (SEE FED NUM 001) DESC 001
CLERICAL OFFICE EMPLOYEES NOC 8810 151,938 .34 517
TOTAL 517
3% MULTI-POLICY DISCOUNT 16- 501
EXPENSE CONSTANT 250 751
TERRORISM-SEE FORM 27317 15 766
CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) 15 781
SEE FORM 27322
TOTAL ESTIMATED ANNUAL PREMIUM 781
ISSUED 5-10-2013
27777 (10-88)(WC000OOlA) 1458
PAGE 2
tAut0-Owners WORKERS, COMPENSATION AND EMPLOYERS' LIABILITY
INSURANCE COMPANY 16144
6101 ANACAPRI BLVD. , LANSING, MI 48917-3999
INFORMATION PAGE RENEWAL AGREEMENT RENEWAL EFF. 06-17-2013
AGENCY HIGH 8 RUBISH INSURANCE AGENCY
15-0936-00 PO BOX 3040 (919) 913-1144 POLICY NUMBER
CHAPEL HILL NC 27515 MKT TERR 050 041715 35022549
ITEM 1
INSURED ORANGE COUNTY LITERACY COUNCIL INC ITEM 2 POLICY PERIOD
COMPANY FROM 12:01 A.M. 06-17-2013
ADDRESS 200 N GREENSBORO ST STE C2 BILL TO 12:01 A.M. 06-17-2014
CARRBORO NC 27510-1833 AT THE INSURED'S
MAILING ADDRESS
FEDERAL ID - 561433933
NC EMPLOYER CODE - 08138060
COUNTY 068
A 3% CUMULATIVE MULTI-POLICY DISCOUNT APPLIES. SUPPORTING POLICIES ARE MARKED WITH AN (X):
COMM UMB( ) COMM PROP/COMM LIABCX) COMM AUTO( ) LIFE( ) PERSONAL( ) FARM( ).
THE PAID IN FULL DISCOUNT DOES NOT APPLY TO FIXED EXPENSE FEES, STATUTORY CHARGES OR
MINIMUM PREMIUMS.
THE PAID IN FULL DISCOUNT IS BASED ON FAVORABLE LOSS EXPERIENCE FOR THE COLLECTIVE GROUP
OF POLICYHOLDERS WHO CHOOSE TO PAY THEIR PREMIUM IN FULL DIRECTLY TO THE COMPANY.
YOUR POLICY QUALIFIES FOR THE PAID IN FULL DISCOUNT IF YOU CHOOSE TO PAY YOUR PREMIUM IN
FULL. YOUR PAID IN FULL DISCOUNT MAY CHANGE AS A RESULT OF POLICY CHANGES. THESE CHANGES
WILL BE REFLECTED IN A FUTURE INVOICE.
TOTAL ESTIMATED ANNUAL PREMIUM 781
PAID IN FULL DISCOUNT 37-
TOTAL POLICY PREMIUM IF PAID IN FULL 744
MINIMUM PREMIUM 8318 NORTH CAROLINA
AUDIT IS - ANNUAL
ENDORSEMENTS:
27011 (WC000308 ) 2703 (WCO00000A) 27043 (WC320301B) 27279 (WC000419 ) 27317 (WC000422A)
27322 (WC000421C) 27942 (WC000414 )
YOU MAY VIEW YOUR POLICY ONLINE AT WWW.AUTO-OWNERS.COM .
TO ENROLL, USE THE POLICY NUMBER 35022549 AND PERSONAL
ID CODE 78A 2N8 G3T.
ISSUED 5-10-2013
27777 (10-88)(WCOOOOO1A) 1459
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PAGE 1
e/luto--Owners WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY
INSURANCE COMPANY ATTACHED TO AND FORMING PART OF
6101 ANACAPRI BLVD. , LANSING, MI 48917-3999
INFORMATION PAGE -RENEWAL AGREEMENT RENEWAL EFF. 06-17-2013
AGENCY HIGH & RUBISH INSURANCE AGENCY
15-0936-00 PO BOX 3040 (919) 913-1144 POLICY NUMBER
CHAPEL HILL NC 27515 MKT TERR 050 041715 35022549
ITEM 1
INSURED ORANGE COUNTY LITERACY COUNCIL INC ITEM 2 POLICY PERIOD
COMPANY FROM 12:01 A.M. 06-17-2013
ADDRESS 200 N GREENSBORO ST STE C2 BILL TO 12:01 A.M. 06-17-2014
CARRBORO NC 27510-1833 AT THE INSURED'S
MAILING ADDRESS
FED NUM 001 STATE NC
FED ID 561433933
ENTITY CORPORATION
NUMBER OF EMPLOYEES 1
ORANGE COUNTY LITERACY COUNCIL INC
200 N GREENSBORO ST STE C2
CARRBORO NC 27510-1833
ISSUED 5-10-2013
2762 (4-84) 1460