HomeMy WebLinkAbout2015-396-E Health - NC Public Health Foundation - Amendment to Quit Line Services Agreement dated 5-1-2014 DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
ORANGE COUNTY
AMENDMENT TO SERVICES AGREEMENT
NORTH CAROLINA
THIS AMENDMENT, made and entered into this the 30"' day of July, 2015, by and between the County of
Orange, a body politic and corporate of the State of North Carolina, ("County"), and The North Carolina Public
Health Foundation("Provider");
WITNESSETH:
WHEREAS, the County and Provider entered into a Services Agreement dated, May 1, 2014, to provide services to
be rendered by Provider to County's Health Department("Original Agreement"); and
WHEREAS, the County and Provider desire to amend the Original Agreement, while keeping in effect all terms
and conditions of the Original Agreement not inconsistent with the terms and conditions set forth below.
NOW THEREFORE, for and in consideration for the mutual covenants and agreements made herein, the parties
agree to amend the Original Agreement as follows:
To change: The term of this Agreement renderered shall be from May 1, 2014 to June 30,2016.
To add Section 11. Signatures. This Agreement together with any amendments or modifications may be executed
electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A
and Article 40 of North Carolina General Statute Chapter 66.
Except for the changes made to extend the Term of the Agreement and to add Section 11 herein, the Original
Agreement shall remain in full force and effect to the extent it is not inconsistent with this Amendment. In the
event that there is a conflict between the Original Agreement and this Amendment, this Amendment shall control.
IN WITNESS WHEREOF, Orange County and the Consultant have signed this Amendment, effective this
the 30th day of July, 2015.
FO . ®R� COUNTY E
��JR XRO VIDER:
j15vi , AJ
By• (lE'i79Q4B75,477 By• f6$6C-90tcD64i ...
County Manager Chuck Bridger, MA , Executive Director
The North Carolina Public Health Foundation
Revised July 2015
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
[Departmental Use Only]
TITLE Quitline
FY 2013-14
ORANGE COUNTY
Service Contract - $15,000.00
NORTH CAROLINA
THIS AGREEMENT, made and entered into this 1St day of May, 2014, ("Effective Date") by and
between Orange County,North Carolina, a body politic and corporate organized under the laws of the State
of North Carolina, (the "County"), parry of the first part; and The North Carolina Public Health Foundation
(the "Provider"),party of the second part;
WITNESSETH:
For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby
contracts for the services of the Provider, and the Provider agrees to provide the following services to the
County in accordance with the terms of this Agreement,time being of the essence:
The services and/or materials (hereinafter referred to collectively as "Services") to be furnished
under this Agreement are as follows: Services as described in Exhibit A, "Cost Sharing Agreement for
QuitlineNC Comprehensive Services" which is attached and hereby incorporated by reference.
The term of this agreement rendered shall be from May 1,2014 to May 31, 2015.
Provider represents and agrees that Provider is qualified to perform and fully capable of performing and
providing the services required or necessary under this Agreement in a fully competent, professional and
timely manner to the satisfaction of the County. Provider shall be responsible for all errors or omissions, in
the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies,
ambiguities, mistakes or conflicts at no additional cost to the County. Provider agrees that Provider shall not
sub-contract any of the services to be provided in this Agreement, nor shall Provider assign any right or
responsibility granted or required by this Agreement,without the prior written approval of the County.
SPECIFIC TERMS
1. Payment: The County agrees to pay at the rates specified for Services satisfactorily
performed in accord with this Agreement. The amount to be paid by the County shall not exceed fifteen
thousand dollars, ($15,000). Payment shall be made within thirty(30) days of an invoice properly submitted
to County. Should Provider fail to perform its duties under the terms of this Agreement, County may, without
fault or penalty,withhold any payment associated with the work to be performed until such time as said work
is completed.
2. Non—waiver: Failure by County at any time to require the performance by Provider of any
of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor
shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of
this Non-Waiver Clause.
3. Independent Contractor: The Provider shall operate as an independent Provider, and the
County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated
as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or
workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of
any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider.
4. Insurance: Provider shall obtain, at its sole expense, Commercial General Liability
Insurance, Automobile Insurance, Workers' Compensation Insurance, Professional Liability Insurance, and
any additional insurance as may be required by Owner's Risk Manager as such insurance requirements are
Revised 9/13 1
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
described in the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage
Requirements (each document is incorporated herein by reference and may be viewed at
http://orangecounlync.gov/purchasing/contracts.asp). If Owner's Risk Manager determines additional
insurance coverage is required such additional insurance shall consist of VJ IN (if no additional insurance
required mark N/A as being not applicable). Provider shall not commence work until such insurance is in
effect and certification thereof has been received by the Owner's Risk Manager.
5. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County
from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable
attorney's fees) arising from bodily injury, including death, to any person or persons or damage to or
destruction of any property caused in whole or in part by any negligent or intentional act or omission on the
part of the Provider.
6. Termination: This Agreement may be terminated at any time by mutual written agreement of
the parties or by the County upon written notice to the Provider. This contract is conditioned on the Provider
entering into a Memorandum of Understanding within 90 days of execution of this Service Agreement with
the Tobacco and Prevention and Control Branch of the Division of Public Health in the North Carolina
Department of Health and Human Services that will enable them to enter into cost sharing agreements with
third parties for QuitlineNC Comprehensive Services.
7. Entire Agreement: The parties have read this Agreement and agree to be bound by all of its
terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between
the parties unless and until modified in writing and signed by the parties. Modifications may be evidenced
by telefacsimile signature.
8. Priori : In determining the basic services to be provided, should any documents be
referenced in this Agreement, the terms herein shall have priority in any conflict between the terms of
referenced documents and the terms of this Agreement.
9. Governing Law:aw: Both parties agree that this Agreement shall be governed by the laws of the
State of North Carolina. Should either party initiate litigation to settle any dispute involving the terms of this
Agreement such litigation shall be initiated in the General Court of Justice of North Carolina seated in
Orange County, North Carolina. Provider shall at all times remain in compliance with all applicable local,
state, and federal laws, rules, and regulations including but not limited to all anti-discrimination laws.
Pursuant to the terms of North Carolina General Statute 153A-449(b) no county may enter into a contract
with a contractor unless the contractor and the contractor's subcontractors comply with the requirements of
Article 2 of Chapter 64 of the North Carolina General Statutes. Where applicable, failure to maintain
compliance with the requirements of Article 2 of Chapter 64 of the General Statutes constitutes Provider's
breach of this Agreement. By executing this Agreement Provider affirms Provider is in compliance with
Article 2 of Chapter 64 of the North Carolina General Statutes.
10. Non Appropriation: Provider acknowledges that County is a governmental entity, and the
validity of this Agreement is based upon the availability of public funding under the authority of its statutory
mandate. In the event that public funds are unavailable and not appropriated for the performance of County's
obligations under this Agreement, then this Agreement shall automatically expire without penalty to County
immediately upon written notice to Provider of the unavailability and non-appropriation of public funds.
[SIGNATURE PAGE TO FOLLOW]
Revised 9/13 2
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
IN WITNESS WHEREOF,Orange County and the Provider have signed this Agreement, effective
as of the day first written above.
ORANG O PROVIDER
By: By: °`--
o my Manager Title: CZ ec Ir",ca,,-
200 S. Cameron St. Elizabeth MacLachlan
North Carolina Public Health Foundation
P.O. Box 8181 5505 Six Forks Road
Hillsborough,NC 27278 Raleigh,NC 27609
This instrument has been approved as to technical content.
—rfi_
f _, ✓
Colleen Bridger,MPH, Ph.D Department Director
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal
Control Act.
- 64�a, A,
Office of the Chief Financial Officer
Ttis ume ias been approved as to form and legal sufficiency.
I
Offi4 of the t9unty Attorney
Revised 9/13 3
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
Exhibit A
Cost Sharing Agreement for QuitlineNC Comprehensive Services
Introduction
The North Carolina tobacco and Prevention and Control Branch (TPCB") of the North Carolina Division of Public Health
in the North Carolina Department of Health and Human Services ("DHHS") works with diverse communities to reduce
tobacco disease, death and health care costs. The North Carolina Tobacco-Use Quitline ("QuitlineNC'), funded by
TCPB, employs scientific evidence-based methods to help tobacco users quit smoking. The North Carolina Public
Health Foundation ("PHF") has entered into a Memorandum of Agreement with TPCB to enable third-parties to enter
into cost-sharing agreements with the PHF for Quitline services. The Orange County Health Department has
expressed interest in becoming a third party payer to expand the sources of payment for purchase Nicotine
Replacement Therapy for Orange County residents enrolled in the QuitlineNC. The following represents a proposal
for service delivery between the Orange County Health Department and the NC Public Health Foundation (PHF).
General Demographic Information
The Orange County Health Department requests Quitline NC provide Nicotine Replacement Therapy for
residents of Orange County,. North Carolina. There are approximately 133,800 residents, of which
approximately [16% (n=21,408)] are tobacco users. Based on historical trends in 2012 and 2013, the
projected "reach" or number of residents expected to call the QuitlineNC for services is 220 per year. Eligible
service users are Orange County residents who are 18 years or older.
Cessation.Service for Orange County Residents
During the period June 1, 2014 — May 31, 2015, Orange County residents that enroll in the Quitline will
receive telephone-based and integrated web-based counseling or web only counseling and free Nicotine
Replacement Therapy (NRT) as follows: an initial telephone screening call, four or eight of weeks of free
nicotine patches, gum, lozenges or combination therapy, up to four counseling calls per member, mailed
materials, and unlimited courtesy calls to the Orange County participant for additional Quitline support.
QuitlineNC participants must speak with a coach to receive free NRT. The Orange County Health
Department will also be able to take advantage of any statewide or nationwide promotion of 1-800-
QuitNow.
Per the Memorandum of Agreement between PHF and the DHHS (see Contract Number 00030671, Scope of
Services), specific service delivery protocol by QuitlineNC will be as follows:
• Initial screening to determine Orange County participant smoking status, provide service explanation
and offer counseling; initial counseling call may be completed "on the spot" if a counselor is
available; otherwise an appointment will be made for a date and time selected by the Orange County
participant. QuitlineNC will initiate the counseling call at the scheduled time. If the Orange County
participant is not reached within a total of four (4) call backs, other attempts will be made to try to
reach the Orange County participant to complete the engagement.
• Up to four (4)telephone counseling sessions (one 45 minute session and three 15 minute sessions)
1
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
Exhibit A
• Eight weeks of nicotine replacement therapy (NRT), based on participation in counseling sessions:
four weeks sent to the Orange County participant home address via UPS upon completion of the
first telephone counseling call (45 min.) and an additional 4 weeks sent via UPS if the Orange
County Health Department participant completes second counseling call.
OR
• Four weeks of NRT sent to Orange County participant home address via UPS upon
completion of the first telephone counseling call.
• An information packet which includes a quit tobacco use guide will be mailed to all participants
completing the screener call. Those who complete the first counseling call and are approved for NRT
will also receive simplified instructions along with the NRT kit.
QuitlineNC Reports
The Orange County Health Department has requested the following reports:
• Monthly aggregate report on services provided, corresponding costs paid with funds from
Orange County Health Department, and remaining balance of funds. Report includes # of
Orange County participants served, by month and year to date, as well as demographics
information, services offered, and amount and type of NRT sent to participants.
Costs for Services, Protocol/Database Changes,Verification,and Outcome Evaluation
Alere Wellbeing, Inc. ("Alere") is the prime vendor to QuitlineNC. Alere, while contracted with the TPCB,
will provide QuitlineNC services, including up to 8 weeks of Nicotine Replacement Therapy, at State specific
unit cost rates. This is a cost-sharing agreement, whereby selected services will be paid by the Orange
County Health Department,while other services will be provided by the TPCB at no cost to the Orange
County Health Department, as shown below:
Pricing structure
Nicotine Replacement Unit Costs 4 weeks 8 weeks
Patches $48.00 per $48.00 $96.00
shipment
Gum $30.00 per box $90.00 $150.00
Lozenges $38.00 per box $152.00 $190.00
Combination Therapy - 4 $108 per 4 weeks $108.00 $156.00
wks patches and two
boxes of gum
In addition, an Administrative fee equal to 5%of the total contract price will be charged for the cost of
administrative services including the monthly cost and aggregate service reports.
2
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
Exhibit A
Promotional Development
The Orange County Health Department agrees to partner with TPCB to initiate promotional development
for roll-out of the project. This will be done on an interim basis. TPCB will let Orange County Health
Department know of any statewide or nationwide media campaigns that will reach Orange County residents.
Payment for Services
The Orange County Health Department will pay directly to Public Health Foundations ("PHF") for participant
services and for the administration fees which include monthly reporting. Orange County Health
Department will make advance payment for contracted services to:
NC Public Health Foundation
PO Box 18763
Raleigh, NC 27619
3
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
Al.la<anceof ALLIANCE OF NONPROFITS FOR INSURANCE
Nonprofits RISK RETENTION GROUP
f-Insurance P.O, Box 8546, Santa Cruz, CA 95061
Risk Retention Cfo-p P: (800) 359-6422
F: (831)459-0853
DIRE TOR ' & OFFICERS' LIABILITY POLICY
DECLARATIONS
Item 1. Named Member: North Carolina Public Health Foundation
Address: P.O. Box 18763
Raleigh, NC 27619
Item 2. Policy Number: 2013-37160-DO
Policy Period: 07119/2013 to 47119/2014
(12:01 A.M. Standard time at the address stated in Item 1.)
tern 3. Limit of Liability: $ 1,000,000 Each Wrongful Act
$ 1,000,000 Annual Aggregate
Item 4. Deductible: N/A
Item 5. Premium $ 2,077
(premium includes Terrorism Coverage- Certified Acts :$19)
Item 6. Applicable policy form(s) and Endorsement(s)effective at inception:
ANI-RRG EDO13 02 11, ANI-RRG-DODEC 04 01, ANI-RRG-DOET 02 11,
AN]-RRG-DOPWA 07 09, ANI-RRG-E3DO 01 99, ANI-RRG-E42 07 06,
ANI-RRG-EDO1 08 91, ANI-RRG-ED011 07 13, ANI-RRG-ED018 04 13,
ANI-RRG-ED034 01 02, ANI-RRG-ED04 03 94, ANI-RRG-ED07 02 11,
CG 2170 01 08, IL 09 85 0,1 08,
Producer: 02522
BB&T Insurance Services- Research Trian
P.O. Box 13941
Research Triangle Park, NC 27709
"NOTICE"
;'his policy is Issued by your risk retention group.Your risk
retention group may not be subject to all of the insurance laws Authorized Company Representative
and regulations of your State.State insurance insolvency President, ANI-RRG a7�zsr2aa
guaranty funds are not available for your risk retention group.•`
ANI -RRG - DODEC
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
A hanceq ALLIANCE OF NONPROFITS FOR INSURANCE
�.� ������ RISK RETENTION GROUP
P.O. Box 8546, Santa Cruz, CA 95061
(j ,for I115ur ace P: (800) 359-6422
Risk Retention Group F: (831)459-0853
DATE: .July 29, 2013
TO: North Carolina Public Health Foundation (37160)
FR: ANI
RE: Avoiding Wrongful Termination Lawsuits
You have recently purchased Directors and Officers coverage with the Alliance of Nonprofits for
Insurance, Risk Retention Group(ANI). Employee-related lawsuits are the most common claim filed
against nonprofit D&O insurance policies. Many of these lawsuits can be avoided by obtaining good
advice before you terminate an employee. To assist you, ANI provides FREE pre-termination
consultation. ,Just contact our Labor and Employment risk managers at 800-359-6422 and they will
assist you to ensure that you take the appropriate actions to protect your organization.
Another service that ANI provides FREE is reviewing your personnel handbook to ensure that it is in
compliance.
You may find these additional facts about employment-related matters of interest:
o Well over 90%of the claims made against directors and officers of 501(c)(3) nonprofits are
employment related. These commonly involve allegations of wrongful terminations,
discrimination, or harassment.
i The primary reason nonprofits find themselves in employment-related lawsuits is failing to
follow, to the letter, personnel policies which are in compliance with law. In particular, if your
personnel policies provide for any special considerations before terminations, such as
grievance, probationary period, or written or verbal warnings, and you do not follow these
policies to the letter, but instead fire immediately in anger, chances are good that you could
find yourself in a lawsuit.
o During our review of personnel policies of those nonprofits with D&O coverage, we most
commonly find policies out-of-compliance with current law regarding pregnancy leave,
provision for payment of overtime, and applicable classes protected from discrimination such
as sexual orientation, political affiliation, veteran status and others.
For everyone's benefit we hope your organization does not find itself in a difficult termination
situation. However, if you do, please do not hesitate to contact our labor and employment risk
managers before you take action so that together we can help minimize your exposure to expensive
and time-consuming lawsuits.
P.S. A knowledgeable, committed board of directors is the strongest protector of a charitable
organization's accountability to the law, its clients, it donors and the public. Are you looking
for a communications and information management solution for your board of directors?
BOARDnetWORK was created by ANI for its member-insureds. This FREE easy to use,
web-based resource will help streamline the process of keeping your board organized and
running smoothly.
View short demo at www.boardnetwork.org. For more information, call our Director of Loss
Control at(831) 621-6076.
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
.A.11xance,,f
Ar Mw
Nonprofits INDEX OF FORMS ATTACHED TO THE POLICY
f-Insurance POLICY NUMBER:2013-37180-D0
Risk Retention Group
NAME OF INSURED: North Carolina Public Health Foundation Page 1
DIRECTORS AND OFFICERS FORMS AND ENDORSEMENTS FORM NUMBER/EDITION DATE
Punitive and Exemplary Damages AN[-RRG ED013 0211
Directors&Officers Liability Policy Declarations ANI-RRG-DODEC 04 01
Nonprofit Organization Directors and Officers Liability Policy ANI-RRG-DOET 02 11
Prior Wrongful Acts Coverage Endorsement ANI-RRG-DOPWA 07 09
Member Criteria ANI-RRG-E3DO 0199
Nuclear, Chemical and Biological Hazard Exclusion ANI-RRG-E42 07 06
Nuclear Energy Liability Exclusion Endorsement(Broad Form) ANI-RRG-EDO1 08 91
Amended Definition of Deductible-Applies to Defense Costs and Damages ANI-RRG-ED011 0713
Revision of Exclusion L AN]-RRG-EDO18 04 13
Mold, Fungus Exclusion ANI-RRG-ED 034 0102
Blood Testing Exclusion ANI-RRG-ED04 03 94
Non-Imputation ANI-RRG-ED07 0211
Cap on Losses from Certified Acts of Terrorism CG 2170 01 08
Disclosure Pursuant to Terrorism Risk Insurance Act IL 09 85 01 08
This list of forms is not part of the actual policy, but is for your information only.
Please refer to the policy(s)for actual limits, coverages and exclusions.
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
Ao f ALLIANCE OF NONPROFITS FOR INSURANCE
Alliance
��� ����� RISK RETENTION GROUP
P.O. Box 8546, Santa Cruz, CA 95061
f-hisuranCe P: (800) 359-6422
WA Retentign Gloup 459-0853
F: ($8 31)
CC3MMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS
PRODUCER: POLICY NUMBER: 2013-37160
BB&T Insurance Services-Research Triangle Region
P.O, Box 13941
Research Triangle Park, NC 27709
NAME OF INSURED AND MAILING ADDRESS:
North Carolina Public Health Foundation
P.O. Box 18763
Raleigh, NC 27619
POLICY PERIOD: FROM 07/1912013 TO 07/1912014
AT 12:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE
BUSINESS DESCRIPTION: Public health program
IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS
POLICY, WE AGREE WITH YOU TO PROVIDE THE COVERAGE AS STATED IN THIS POLICY.
LIMITS OF COVERAGE:
GENERAL AGGREGATE LIMIT(OTHER THAN PRODUCTS-COMPLETED OPERATIONS) $2,000,000
PRODUCTS-COMPLETED OPERATIONS AGGREGATE LIMIT ............................ $2,000,004
PERSONAL AND ADVERTISING INJURY LIMIT ................................................... $1,000,000
EACHOCCURRENCE LIMIT .................................................................................. $1,000,000
DAMAGE TO PREMISES RENTED TO YOU ........................................................ $500,000 any one premise
MEDICALEXPENSE LIMIT ...................................................................................... 20,000 any one person
ADDITIONAL COVERAGES:
SOCIAL SERVICE PROFESSIONAL LIABILITY EXCLUDED
CLASSIFICATION(S) SEE ATTACHED SUPPLEMENTAL DECLARATIONS SCHEDULE G
PREMIUM $844
FORMS AND ENDORSEMENTS APPLICABLE TO THIS POLICY ARE INCLUDED IN COMMERCIAL LINES COMMMON POLICY DECLARATIONS
07/29/2013 BY
(AUTHORIZED REPRESENTATIVE)
THESE DECLARATIONS AND THE COMMON POLICY DECLARATIONS,IF APPLICABLE,TOGETHER WITH THE COMMON POLICY CONDITIONS,COVERAGE FORM(S)
AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED To FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY.
"NOTICE :This Policy is issued by your risk retention group.Your risk retention group may not be subject to all
the insurance laws and regulations of your State.State insurance insolvency guaranty funds are not available for
your risk retention group."
ANI .RRG -GI_ (02622)
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
1a>r1C 'nf ALLIANCE OF NONPROFITS FOR INSURANCE
1�,
RISK RETENTION GROUP
Mff
Nonprofits P.O. Box 8546, Santa Cruz, CA 95061
AV f-Insurance P: (804)359-6422
Risk Retention Group F: (831)459-0853
COMMERCIAL GENERAL LIABILITY
EXTENSION OF DECLARATIONS
Schedule G
POLICY NUMBER: 2013-37160 Page 1
NAME OF INSURED: North Carolina Public Health Foundation
PREMISES PREMIUM *ADVANCED
CODEICLASS *LOC BASIS RATE PREMIUM
47356 1Sales, Service or Consulting Organizations- 1 833,996 .652 $543
NOC-includes products and/or completed
operations
ADDITIONAL COVERAGES
.ncreased Aggregate $117
Additional Premium to Meet Minimum $184
*See Common Declarations for Total Advanced Premium and Schedule'L'for locations.
x-
07/29/2013 BY
(AUTHORIZED REPRESENTATIVE)
"NOTICE : This Policy is issued by your risk retention group.Your risk retention group may not be subject to all
the insurance laws and regulations of your State.State insurance insolvency guaranty funds are not available for
your risk retention group."
ANI -RRG -SCHEDULE G (02522)
DocuSign Envelope ID: 7F8DFDB2-D81A-4AOF-AF96-9B69F601FC96
ALLIANCE OF NONPROFITS FOR INSURANCE
Allxanceof RISK RETENTION GROUP
".-iNonprofits P.O. Box 8546, Santa Cruz, CA 95061
f-Insurance P: (800) 359-6422
Risk Retention Group F: (831)459-0853
COMMERCIAL GENERAL LIABILITY
EXTENSION OF DECLARATIONS
Schedule L
POLICY NUMBER: 2013-37160 Page I
NAME OF INSURED: North Carolina Public Health Foundation
PREMISES DESIGNATED PREMISES ADDITIONAL INSUREDS
LOCJBLDG ADDRESS CITY STATE ZIP AND OTHER INTERESTS
1 Mailing only
Raleigh, NC 27619
07/29/2013 BY
(AUTHORIZED REPRESENTATIVE)
"NOTICE :This Policy is issued by your risk retention group.Your risk retention group may not be subject to all
the insurance lags and regulations of your State.State insurance insolvency guaranty funds are not available for
your risk retention group."
ANI -RRG-SCHEDULE L (02522)