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HomeMy WebLinkAbout2015-463-E Finance - Senior Care of Orange County, Inc. - 2015-16 Outside Agency Performance Agreement $25,000 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 2015-16 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2015, ("Effective Date")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 Senior Care of Orange County, Inc, a not-for-profit corporation, located at 105 Meadowland Drive, Hillsborough,NC 27278 ("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 Senior Care of Orange County, Inc agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2015 to June 30, 2016. 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 S 25,000. 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 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 discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $6,250. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Senior Care of Orange County,Inc) Orange County Outside Agency Performance Agreement Page 1 of 7 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 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 Progress Report that includes a fiscal report and updates on 2015-16 performance measures as outlined in the 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 11, April 15, and July 8 of the program fiscal year. b. 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: 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. (Senior Care of Orange County,Inc) Orange County Outside Agency Performance Agreement Page 2 of 7 Rev. 6115 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 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: 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 (Senior Care of Orange County,Inc) Orange County Outside Agency Performance Agreement Page 3 of 7 Rev. 6115 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have 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. 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 $12.76 per hour. To the extent possible, Orange County recommends that Senior Care of Orange County, Inc 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 (Senior Care of Orange County,Inc) Orange County Outside Agency Performance Agreement Page 4 of 7 Rev. 6115 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 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: Finance &Administrative Services Provider: Senior Care of Orange County, Orange County Inc Post Office Box 8181 105 Meadowland Drive Hillsborough,NC 27278 Hillsborough,NC 27278 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. 19. 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. 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 behalf of the Provider DocuSigned by: 8/21/2015 S'1'M,ffLqtt62B65 BB44a_ Date Alvonia Baldwin Printed Name For and on behalf of Orange County Government -DocuSigned by: b6VukA'f, t Ammtys 8/24/2015 9romik,9141afffffi-ersley, County Manager Date (Senior Care of Orange County,Inc) Orange County Outside Agency Performance Agreement Page 5 of 7 Rev. 6115 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 ATTACHMENT "A" Orange County Certifications-FY 2015-16 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. DocuSigned by: Director Certified by: a"- -' � Title: Date: 8/21/2015 PViffV®§4Signature) (Senior Care of Orange County,Inc) Orange County Outside Agency Performance Agreement Page 7 of 7 Rev. 6115 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 EXHIBIT"A" Scope of Services—FY 2015-16 Outside Agency Performance Agreement Agency Name: Senior Care Of Orange County; Inc. Program Name: Florence Gray Soltys Adult Day Health Program Funding Award: $25,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Participant Funding $15,000 Program Supplies/Snacks $2,000 Personnel(Salaries,FICA and Fringe Benefits) $6,000 Marketing/Oufteach/Staff Development $1,000 Transportation $1,000 Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • To continue to provide a therapeutic health model focus to the participants by promoting independence,wellness, socialization and emotional well being in a community based setting. • Provide additional respite support services and resources for the families that we serve through quarterly trainings and inservices • To support the continuation of additional program supplies when census increases Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange Coun y,,only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results To prevent and/or prolong most participants with health conditions from becoming 85 isolated and/or institutionalized Continue to increase enrollment maintaining a daily average census of 24 participants 75 per day Continuation of respite support for caregivers while supporting the needs of the 100 participant. DocuSigned by: E7B5052B65BB443... Certified by: I le: I✓e G 74-- Date: 1Z (Provider's Signature) DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 L&P Contribution Notice Liability & Property Declarations N O R T A R O L I N A ASSOCIATION OF COUNTY COMMISSIONERS RISK MANAGEMENT POOLS Contract General Provisions Covering the Counties that Cover our State Property Coverage 'Woen or %C;'hare of 4 1 AML Aglb urange uounty- Business Automobile Coverage iD July 1 , 2015-July 1 , 2015 Crime Coverage Liability & Property Pool Contribution Notice, Public Official Liability Declarations and Coverage Documents Employment Practices Liability Environmental Impairment Liability Coverage Cyber Liability and Expense NCACC Staff NCACC Risk Control Services O Copyright 4 12 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 r N o R T H C A R o I. T N A NCACC Risk Management t Pools AssOCIATION OF COUNTY COMMISSIONERS Liability and Propei-ty SECTION V PUBLIC OFFICIALS LIABILITY CONTRACT DECLARATIONS Participant SENIOR CARE OF ORANGE COUNTY CO., INC Contract Number LP-SE-525-15 Contract Period July 1, 2015 to July 1, 2016 Effective Time 12:01 A.M., Eastern Daylight Time SCHEDULE OF COVERAGES AND LIMITS COVERAGE LIMIT Coverage Agreement A, Public Officials'Wrongful Act, Each Occurrence $2,000,000 Coverage Agreement B, Sexual Misconduct, Each Person $500,000 Coverage Agreement B, Sexual Misconduct, Per Contract Period $1,000,000 DEDUCTIBLE Coverage Agreement A, Public Officials Wrongful Act, Each Occurrence $5,000 Coverago Agreement B, Public Officials Wrongful Act, Each Occurrence $5,000 { NCACC RMP Public Officials Liability Declarations Page Issued Edition 71112614 4 7/10/2015 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 SECTION V: PUBLIC OFFICIALS LIABILITY COVERAGE i The Pool agrees with the Participant in consideration of the payment of the contribution and in reliance upon the statements in the Application and subject to the limits of liability, exclusions, conditions, and other terms of this Contract as follows: A. Public Officials Liability Coverage Agreement 1. The Pool will pay on behalf of a Covered Person any Damages the Covered Person becomes legally obligated to pay because of a Public Officials Wrongful Act that occurs during the Contract Period. 2. The Pool shall have the right and duty to defend any claim or Suit against a Covered Person alleging a Public Officials Wrongful Act for which coverage is afforded under Section V(A)(1), 3, The coverage afforded under Section V(A)(1) shall not apply to punitive damages, attorney's fees, treble damages, fines, penalties, or multiplied damages. B. Limited Sexual Misconduct Coverage Agreement 1. The Pool will pay on behalf of a Covered Person any Damages for Bodily Injury or Personal Injury the Covered Person becomes legally obligated to pay because of Sexual Misconduct occurring during the Contract Period, where such Damages were caused by the Covered Person's negligence in hiring, training or supervision practices. $ 2. The indemnity coverage afforded under Section V(B)(1) shall not apply: a. on behalf of a Covered Person who personally commits Sexual Misconduct; b. on behalf of a Covered Person who remains passive upon gaining any knowledge of Sexual Misconduct; or c. to punitive damages, attorney's fees, treble damages, fines, penalties, or multiplied damages. 3. The Pool shall have the right and duty to defend any claim or Suit against a Covered Person in which Sexual Misconduct covered under Section V(B)(1) is alleged. In accordance with Section V(D) (Defense Costs and Expenses), coverage for costs and expenses the Pool incurs in defending such claims or Suits shall be provided in addition to any applicable limits and/or sub- limits of liability. 4, The Pool shall have the right and duty to defend any claim or Suit for which indemnity coverage is excluded pursuant Section V(B)(2)(a) and/or Section V(B)(2)(b); however, the costs and expenses the Pool incurs in defending such claims or Suits shall erode any applicable limits and/or sub-limits of liability. 5. The coverage afforded under this Section V(B) (Limited Sexual Misconduct Coverage Agreement) is subject to the following sub-limits of liability: a. $500,000.00 per person alleging Sexual Misconduct, regardless of the number of claimants, claims made, incidents involving that person, or the number of Covered Persons involved. b. $1,000,000.00 aggregate per Contract Period. NCACC RMP PUBLIC OFFICIALS LIABILITY SECTION Page 1 of 9 EDITION 7/1/2015 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 C. Immunity The parties to this Contract intend for no coverage to exist under Section V (Public Officials Liability is Coverage) as to any claim for which the Covered Person is protected by sovereign immunity and/or governmental immunity under North Carolina law. It is the express intention of the parties to this Contract that none of the coverage set out herein be construed as waiving in any respect the entitlement of the Covered Person to sovereign immunity and/or governmental immunity. D. Defense Costs and Expenses 1. Except as stated in Section V(B)(3), for any claim or Suit the Pool defends for which coverage is afforded under this Section V of the Contract, the Pool will pay at its expense, in addition to the limits of liability stated in the Contract Declarations and Section V(G), and the sub-limits of liability stated in Section V(13)(4): a. Expenses incurred in the investigation, adjustment, defense, and settlement of covered claims or Stilts; b. Other reasonable expenses, except salaries of a Covered Person, incurred by a Covered Person at the Pool's request; and c. Court costs required by law, including pre-judgment interest. 2. However, if the Pool defends any claim or Suit for which coverage is not afforded under this Section V of the Contract, the Pool shall have the right to seek reimbursement from the Participant for any costs and expenses the Pool incurs in defending any uncovered claim or Suit. E. Covered Persons The following are Covered Persons, as the term is used in this Section V of the Contract: 1. The Participant; 2. Lawfully elected or appointed officials of the Participant while acting under the jurisdiction of the Participant and within the course and scope of his or her authority as a lawfully elected or appointed official under the jurisdiction of the Participant; 3. Employees of the Participant or employees of lawfully elected or appointed officials of the Participant working at the direction or control of a lawfully elected or appointed official of the Participant, but only while working within the course and scope of their employment, and provided the employee is not a Covered Person under any other Section of the Contract; and 4. Members of a commission, board, or other unit operating under the jurisdiction of the Participant, within apportionment of its total operating budget. Coverage shall not apply to any of the following boards, commissioners, or units, unless specifically endorsed hereon or specifically included on the Application: schools, airports, transit authorities, hospitals and health clinics, municipally- owned gas or electric companies, housing authorities, or fire stations. However, coverage shall apply to transit authorities and health clinics owned by a health department, which have paid a premium to the Pool to be included as a named Participant under the Contract. NCACC RMP PUBLIC OFFICIALS LIABILITY SECTION Page 2 of 9 EDITION 7/9/2038 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 rklNorm uaronna vvorlKers- Compensation Insurance Plan exy, Riverport Insurance Company NCCI Carrier Code 27995 Administered by Berkley Assigned Risk Services ASSIGNED RISK SERVICES P.O. Box 59143, Minneapolis, Minnesota 55459-0143 Toll Free(888)548-7431 Fax(866)215-8118 www.berkleyassignedrisk.com .policyservices @berkleyrisk.com INFORMATION SCHEDULE Renewal Of No, WC-32-90-015265-03 1. The Insured: WCIP Policy Number: WC-32-90-015265-04 Risk ID: Senior Care of Orange County PO Box 8181 Attn Health Center Tax ID#: Hillsborough, NC 27278 Policy Period: From: 2/8/2015 To: 218/2016 Endorsement Eff. Date: 218/2015 Date of Mailing: 1/7/2015 Changes as set forth below are hereby made,with respect to the estimated remuneration, premium and/or rates. Total Estimated Annual Premium $3,185.00 Policy Summary 2/8/2015- 2/8/2016 Manual Premium $2,783.00 Increased Limits 1.008 $22.00 Increased Limits Minimum $53.00 Subject Premium $2,858.00 Modified Premium $2,858.00 Standard Premium $2,858.00 Expense Constant $250.00 Terrorism 0.02 $51.00 Catastrophe 0.01 $26.00 Total Estimated Annual Premium $3,185.00 Total Fees&Premium $3,185.00 Net Deposit Premium Required $3,185.00 Premium Paid to Date ($3,185.00) Refund $0.00 All other terms and conditions of this policy remain unchanged. Agency Name and Address BB&T Ins Services Inc 414 Gallimore Dairy RD Ste F Greensboro, NC 27409 Page 2 of 2 WC990001A DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 rkl North Carolina Workers' Compensation Insurance Plan Beiz;y Riverport Insurance Company NCCI Carrier Code 27995 Administered by Berkley Assigned Risk Services ASSIGNED RISK SERVICES P.O. Box 59143, Minneapolis, Minnesota 55459-0143 Toll Free(888)548-7431 Fax(866)215-8118 www.berkleyassignedrisk.com policyservices @berkleyrisk.com ENTITY AND LOCATION SCHEDULE 1. The Insured: WCIP Policy Number: WC-32-90-415265-04 Risk ID: Senior Care of Orange County PO Box 8181 AtEn Health Center Tax ID#: Hillsborough, NC 27278 Policy Period: From: 21812075 To: 218/2016 Indorsement Eff. Date: 2/8/2015 Date of Mailing: 117!2015 Entity Information: Insured Name: Senior Care of Orange County Individual L Partnership Federal ID Number: F 56-2460614 [X]Corporation Other UIC Number: 105 Meadowland Dr Hillsborough, NC 27278 Agency Name and Address BB&T Ins Services Inc 414 Gallimore Dairy RD Ste F Greensboro, NC 27409 WC990601 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 Berkivy^ North Carolina Workers' Compensation Insurance Plan t' Riverport Insurance Company NCCI Carrier Code 27995 Administered by Berkley Assigned Risk Services ASSIGNED RISK SERVICES P.O. Box 59143,Minneapolis,Minnesota 55459-4143 Toll Free(888)548-7431 Fax(866)215-8118 www.berkleyassignedrisk.com policyservices @berkleyrisk.com PARTNERS OFFICERS AND OTHERS EXCLUSION ENDORSEMENT 1. The Insured: WCIP Policy Number: WC-32-90-015265-04 Risk ID: Senior Care of Orange County PO Box 8181 Attn Health Center Tax ID#: Hillsborough, NC 27278 Policy Period: From: 218I2015 To: 218/2016 Endorsement Eff. Date: 2/8/2015 Date of Mailing: 1/7/2015 This policy does not cover bodily injury to any person described in the schedule. The Premium basis for the policy does not include the remuneration of such persons. You will reimburse us for any payment we must make because of bodily injury to such persons. SCHEDULE Partners Officers Others Jack Chesnut Jerry Passmore Ed Flowers Mary Ann Peter All other terms and conditions of this policy remain unchanged. Agency Name and Address BB&T Ins Services Inc 414 Gallimore hairy RD Ste F Greensboro, NC 27409 WC 00-03-08 315 DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 C a PO BaX 59689 Nrmfn ham AL 35259-9889 phone: 800 824-9709 Fax "0 879-3739 ATTN.- Carol Smith Email: JCarol.Smith@_bbandtcom AGENCY; 1313&T-Commercial Client Center QUOTATION EXP DATE: 711312016 We are pleased to confirm the following quotation that has been received from the carrier shown below. Please note that this quotation is based on the coverage,terms and conditions listed below, which may be different from those requested in your original submission. As you are the representative of the insured,i is incumbent upon you to review the terms of this quotation carefully with your Insured,and reconcile an differences from the terms requested in the original submission. CRC Insurance Services, Inc. disclaim any responsibility for your failure to reconcile with the Insured any differences between the terms quote Blow and those terms originally requested. THIS COVERAGE MAY NOT BE BOUND WITHOUT A FULL EXECUTED BROKERAGEAGREEMENT. The terms of the quotation are as follows: Insured Name: Senior Care of Orange County, Inc. Description: Q--' L'-LA PAIJ Carrier: Evanston Insurance Company Form: CLAIMS MADE Tenn: 7/13/2015 to 7/13/2016 Limit: Professional Liability $1,000,000 Each Claim $3,000,000 Aggregate General Liability $1,000,000 Each Claim Coverage A $1,000,000 Each Claim Coverage B $5,000 Limit Med Pay Coverage C $3,000,000 Limit Aggregate All Coverages Deductible: Professional Liability $5,000 Each Claim General Liability $5,000 Each Claim Terms&Conditions: The Insurance Carrier indicated in this quotation reserves the right,at its sole discretion,to amend or withdraw this quotation if the Carrier becomes aware of any new,corrected or updated information that the Carrier believes would be a material change and would cause them to change their original underwriting decision. Premium is due upon receipt of invoice. Fees are fully earned upon binding. 25%Minimum Earned Premium Retro active date: July 13,2005 for GL and PL Rate: FLAT DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 Policy Form: SM-20003-01 04108-Specified Med Professions General Liability Insurance(Including Products and Completed Operations Liability)-Claims Made Specified Med Professions Professional Liability Insurance-Claims Made(claims made form) Professional Liability: Professional Services: Adult Day Care Note: The Professional Liability Insurance Coverage Part contains provisions that reduce the limits of liability stated in the policy by the costs of legal defense and permit legal defense costs to be applied against the deductible, unless the policy is amended by endorsement General Liability: *Coverage A. Bodily Injury and Property Damage Liability 1 Coverage A: $50,000 damage to premises-any one premise i3Coverage B: Personal Injury and Advertising injury Liability `Coverage C: Medical Payments -Each Injured Person Specified Products,Goods,Operations and Premises: Adult Day Care Services,all related premises and operations of the Insured The Premises Hazard and Operations Hazard excludes all pollution cleanup. Note: The General Liability Insurance Coverage Part contains provisions that reduce the limits of liability stated in the policy by the costs of legal defense and permit legal defense costs to be applied against the deductible,unless the policy is amended by endorsement Extended Reporting Period (bi-lateral): 12/24/36 months for 150%1175%/200%of the total annual premium,respectively Up to 7 years Extended Reporting Period available:See Endorsement MEIL 5229 09 10,attached. Endorsements: EIC 4115-01 25%Minimum Earned Premium Endorsement EIC 832-01 Asbestos Exclusion ZZ-44002-01 Mold Exclusion MEIL 5229 09 10 Longer Duration Extended Reporting Period Availability EIC 4638 01 15 Certified Acts of Terrorism Endorsement MEIL 5410 02 12 Amendment of Definitions and Exclusions-Electronic Data and Distribution of Material in Violation of Statutes MEIL 1313 0212 Amendment of Definitions and Exclusions-Electronic Data and Distribution of Material in Violation of Statutes MEIL 1228 0214 Non-Stacking Limitation When Two Or More Policies Apply ZZ 50000 0115 Policyholder Disclosure Notice of Terrorism Insurance Coverage MESM 3017 0515 Exclusion-Unmanned Aircraft EIC 4661 Additional Insured Endorsement for Landlords,Sponsors or Lessors MESM 2098 0414 Good Samaritan Endorsement MESM 2034 04 11 DataBreach Coverage Parts Endorsement DocuSign Envelope ID: 3FD37DED-3EFC-49BB-BD08-D6EFCA4FEB76 NOTE: If Insured is located outside yourresident stafe we must receive a Copy of vour non-resident license gELpr to binding, If coverage is elected,please note: Tammy Walton National Producer Number 5542887 The insurance company with which this coverage has been placed Is not licensed by the State of North Carolina and is not subject to its supervision. In the event of the insolven gqy of the Insurance conligany, losses under this Poky will not be paid 12y an State insurance guaranty or solvengy fund. Premium- $4,500.00 Agency Fee $500.00 State Tax $225.00 Total: $5,225.00 AGAIN, KEEP IN MINI]THAT THE COVERAGES OFFERED IN THIS QUOTATION MAY DIFFER FROM THAT REQUESTED IN THE APPLICATION. FAILURE TO PROVIDE THE REQUESTED COVERAGE SHALL IMPOSE NO LIABILITY ON CRC INSURANCE SERVICES,INC.OR ITS COMPANIES. CRC is compensated in a variety of ways, including commissions and fees paid by insurance companies and fees paid by clients. Some insurance companies pay brokers supplemental commissions (sometimes referred to as "contingent commissions" or"incentive commissions"),which is compensation that is based on a broker's performance with that carrier. These supplemental commissions may be based on volume, profitability, retention, growth or other measures_ Even if a contingent commission agreement exists with a carrier,we recognize that our responsibility is to promote the best interests of the policyholder in the selection of an insurance company. For more information an CRC's compensation,please contact your CRC broker. Financing Insurance Premiums Premium financing budgets insurance payments and improves liquidity for other business objectives:working capital,business growth,building expansion. If your clients choose to pay their insurance in monthly installments,it's fast and easy with AFCO&Prime Rate Insurance Premium Finance Companies,which are affiliates of CRG.AFCO provides premium financing solutions for large and mid-size corporate accounts;Prime Rate offers solutions for smaller commercial and personal lines_ Find out how premium financing works and how it can expand your relationship with your clients by e- mailing remiumfinance afco.com;or call toll-free 866-669-0937 and press 89-Additional information Is available at www_afco.com and www.primeratel)fo.com. Thank you for giving us the opportunity to work on your business.