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Home My WebLink About2016-320-E Health - Triangle Urology Associates, P.A. - vasectomy services to OCHD referred males DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 [Departmental Use Only] TITLE TriangleUrology-Steriliz. FY 2016-2017 ORANGE COUNTY CONTRACT UNDER$15,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this 1st day of July, 2016, ("Effective Date")by and between Orange County, North Carolina, a political subdivision of the State of North Carolina, (the "County"),party of the first part; and Triangle Urology Associates, P.A. (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: Provider will perform vasectomy and post-procedure semen analysis to uninsured males referred by Orange County Health Department. OCHD will pay Provider $800 per procedure performed inclusive of the post-precedure semen analysis. The term of this agreement rendered shall be from July 1, 2016 to June 30, 2017. 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 Eight Thousand dollars, ($8,000). 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 contractor 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, and any additional insurance as may Revised 6/16 1 DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 be required by County's Risk Manager as such insurance requirements are 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://www.orangecountync.gov/departments/purchasing division/contracts.php). If County's Risk Manager determines additional insurance coverage is required such additional insurance shall consist of N/A (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 County'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, its agents, or assigns directly or indirectly related to the Services to be performed pursuant to this Agreement 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. County may suspend this Agreement upon reasonable notice to the Provider. 7. Entire Agreement and Signatures: 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. 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. 8. Priority: In determining the basic services to be provided, should any documents be referenced in or attached to this Agreement, the terms of this Agreement shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. 9. Governing Law: Both parties agree that this Agreement shall be governed by the laws of the State of 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 state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Anti-Discrimination Policy. Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 10. Dispute Resolution: Any and all suits or actions to enforce, interpret, or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County,North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. 11. 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 Revised 6/16 2 DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 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 6/16 3 DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 IN WITNESS WHEREOF, County and the Provider have signed this Agreement, effective as of the day first written above. O W9 ,e�,1 NTY PR DERed by: By: 06-3-799#B-55E477... County Manager Title: 200 S. Cameron St. Triangle Urology Associates,P.A. P.O. Box 8181 205 Frasier Streeet Hillsborough,NC 27278 Durham,NC 27704 Revised 6/16 4 DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 Hanover Insurance Group_ WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 2 WORKERS COMPENSATION AMENDED INFORMATION PAGE ENDORSEMENT EFFECTIVE 06/25/2016 NUMBER 01 REASON AMENDED: EFF 06/25/16 DELETE BUREAU FILLING# SUPERSEDES ANY PREVIOUS DECLARATIONS BEARING THE SAME NO. FOR THIS POLICY PERIOD CARRIER CODE NO. 29661 Policy Number Policy Period Coverage is Provided in the Agency Code From To W26-A004288-03 06/25/2016 06/25/2017 _ ALLMERICA FINANCIAL BENEFIT INSURANCE 1902820 ITEM 1. Named Insured and Address Agent Telephone: 866-635-9736 TRIANGLE UROLOGY ASSOCIATES PA MOORE &JOHNSON AGENCY ATTN: DAVIN BROWN CL HANOVER CSC 205 FRASIER ST PO BOX 17867 DURHAM, NC 27704 RALEIGH, NC 27619 Federal ID No. SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER WORKPLACES NOT SHOWN ABOVE. IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE. ENTITY OF INSURED - CORPORATION ITEM 2. POLICY PERIOD- 06/25/16 TO 06/25/17 12:01 AM STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN. ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES- , NC. B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A. D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING PART OF THIS POLICY. ITEM 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. CLASSIFICATION OF OPERATIONS EST ANNUAL PREMIUM SEE ATTACHED SCHEDULE OF OPERATIONS 3,684 MINIMUM PREMIUM $261 EXPENSE CONSTANT 210 PREMIUM FOR TERRORISM $123 PREMIUM FOR CATASTROPHE $123 TOTAL ESTIMATED ANNUAL PREMIUM $4,140 DEPOSIT PREMIUM $4,140 THE FOREGOING AMENDMENT RESULTS IN AN ADDITIONAL PREMIUM OF $0 COUNTERSIGNED THIS DAY OF AUTHORIZED REPRESENTATIVE BRANCH OFFICE:13840 BALLANTYNE CORP PL SUITE 100 CHARLOTTE NC 28277 Form 331-0226 (9-03) WC000001 B Date Issued: 04/29/2016 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL 492 WCDEC1 DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 41-lanover Insurance Group_ WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY ^2 EXTENSION OF INFORMATION PAGE - AMENDED POLICY ENDORSEMENT EFFECTIVE 06/25/2016 NUMBER 01 REASON AMENDED: EFF 06/25/16 DELETE BUREAU FILLING# SUPERSEDES ANY PREVIOUS DECLARATIONS BEARING THE SAME NO. FOR THIS POLICY PERIOD CARRIER CODE NO. 29661 Policy Number Policy Period Coverage is Provided in the Agency Code From To W26-A004288-03 06/25/2016 06/25/2017 ALLMERICA FINANCIAL BENEFIT INSURANCE 1902820 ITEM 1. Named Insured and Address Agent Telephone: 866-635-9736 TRIANGLE UROLOGY ASSOCIATES PA MOORE &JOHNSON AGENCY ATTN: DAVIN BROWN CL HANOVER CSC 205 FRASIER ST PO BOX 17867 DURHAM, NC 27704 RALEIGH, NC 27619 Federal ID No. POLICY ** A D D I T I O N A L L O C A T I O N S ** SCHEDULE PAGE 2 PAGE 1 LOCATION ADDRESS NUMBER 001 205 FRASIER STREET DURHAM NC 27704 Form 331-0226 (9-03) WC000001B Date Issued: 04/29/2016 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL WCOEC1 493 DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 Insurance Group_ i RENEWAL OF POLICY COMMERCIAL UMBRELLA POLICY THESE DECLARATIONS TOG COMP WITH E THE COMON NUMB POLICY CONDITIONS AND COVERAGE ICY POLICY NUMBER: OD6-A005679-03 DECLARATIONS Agent Named Insured and Address (No., Street, Town, County, State) TRIANGLE UROLOGY ASSOCIATES, 190282000 MOORE & JOHNSON AGENCY ATTN: DAMN CL HANOVER CSC 205 FRASIER ST. PO BOX 17867 DURHAM, NC 27704 RALEIGH, NC 27619 Policy Period: (Month, Day, Year) From 06/25/2016 To 06/25/2017 12:01 AM, standard time at the address of the Named Insured as stated herein. Form of Business: ❑ Individual ❑ Partnership IN Corporation Q Limited Liability Company ❑ Organization (Other than Partnership, Joint Venture, or Limited Liability Company Business Description: OFFICE. THIS POLICY, IN RETURN THE PAYMENT OF THE PREMIUM, AND SUBJECT WE AGREE WIDTH YOU TO PROVIDE THE INSURANCE AS STATED IN ALL OTHIS POLICY.RMHISOPREMIUM MAY BE SUBJECT TO AUDIT. Limit of Liability (Section III) $ 1,000,000 Each Occurrence Limit $ 1,000,000 General Aggregate Limit Product Completed Operations Aggregate Limit $ 1,000,000 Retained Limit Self-Insured Retention $ NIL Premium Computation Annual Premium $ 400.00 Advance Premium $ 400.00 Endorsements: CU2130 01/15 C112156 06/06 CU2136 01/15 473-0004 10/05 CU0004 05/09 473-0016 10/05 473-0023 10/05 473-0040 10/05 473-0067 03/05 1L0017 11/98 473-0025 473-1125 02/09 CU2436 12/05 CU2150 0025 03/06 CU2186 05/14 PRE PAID - the total annual premium is due at inception. HANOCASH -the annual premium is payable according to the term of the Hanocash endorsement attachment —ACCOUNT BILL X DIRECT BILL Q Annual ❑ Semi-Annual ❑ Other Audit period: Non Auditable Unless indicated by 0 Annual Semi-Annual ❑ Other If you cancel this policy, we shall receive and retain not less than $ as a policy minimum premium. 473-1102 1108 9,599 DocuSign Envelope ID 58340D10-53F7-460D-9D47-DA2ED9BEB980 "t*nanover 1902820 or .1,1 LE A - SCHEDULE OF UNDERLYING POLICIES d: TRIANGLE UROLOGY ASSOCIATES, and after: 06/25/2016 , 12:01 AM Standard Time is QD�-�80�G�9-Q3 ' 'CARRIER, POLICY NUMBER & PERIOD TYPE OF POLICY APPLICABLE LIMITS OR AMOUNT OF INSURANCE 1UOO Commercial 1,000,000 Each Duournencl ((a)Carrier: d Genera| Liabi|ih/ $ 2.l[D.ODO Genera| Agg'eQo WASSACHUSETTS BAY |NSUHANCE COMPANY Non-owned & 2,000,000 Product/Complet dAubm� Operations Policy 0D6-A005679'03 Hired Aggregate PV|icyPeriod: 00/25/2018 T(] 06/25/2017 Comprehensive Bodily Injury and Property (b) Carrier: AutompbUe Liability Damage Liability Combined � Each Accident Policy Number: Bodily Injury Person Policy Period: - EochAccident Property Damage � Each Accident (c)Carrier: Standard Workers Coverage B - Employers LiabiQ1 Compensation & Bodily by Accident ALLN\ERiCAF|N8NC|AL BENEFITS INSURANCE C Employers Liability $ 500.000 Each Accident Policy Number: VV26A00428803 Please Note: Bodi� ��rybyDisease Umbrella Coverage $ 500'000 Aggregate Policy Period: 06/25/2016 TO 06/25/2017 for Worke 500000 EVchEmp\oye' Compensation and Employers Liability is not applicable in situations where an employee is subject to the New York Workers Compensation Law. (d)Carrier: Liquor Liability Limit of Liabili Policy Number: Policy Period: (e)Carrier: Professional Limit of Liabil Liability Policy Number: Policy Period: An "X" marked in the box provided indicates these broadening or optional coverages are provided in the Underlying Insurance (f) Carrier: Directors & Officers $ Lim� ofLiabi � Liability Policy Number: Policy Period: Benefits $ Limit of(g) Employee Benefits nn� Liability Policy Number: Policy Period: Countersigned By: Date: Authorized Representative of the Company 473-1103 (11/08) 9,600 . -.--- m MIN ��c�m DocuSign Envelope ID: noo*uo1u'nnpr�ouo'eo4r'oAzeoeoeoeou - Insurance G --'_ --- 0DGAO0S678 1902820 LIMITED FUNGI OR BACTERIA LIABILITY COVERAGE ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE - Fungi and Bacteria Liability Aggregate Limit $ 50.000 "bodily injury" or "property damage" and The following provisions are added to SECTION || - Medical Payments arising out of a "fungi or LIABILITY: baoteria incident". This provision D'1' does A. The following is added to Part B. Exc|ueioma, not apply to any"fungi" or bacteria that are, paragraph 2.: are on, or are contained in, a good or m. Arising out of a "fungi or bacteria incident". product intended for bodily consumption. B. The following is added to Part B. Exc\usioms, 2. Paragraphs 0-2. and Q,3- of the Liability and Medical Expenses Limits of Insurance paragraph 2.k.: continue to apply to "bodily injury" or (3) Abating, testing 0mr, monitoring, cleaning up, "property damage" arising out of a "fungi or nsmov|ng, containing, treat|ng, deto»iYyinQ, bacteria incident", but only if, and to the neutra|iz|nQ, remediating or disposing of, or extent that, limits are available under the in any way responding to, or assessing the Fungi and Bacteria Liability Aggregate Limit. effects of, "fungi" or bacteria, by any insured or by any other person or entity. E. The following definitions are added to Part F. Liability Medical Expenses Definitions: C. Coverage provided by this insurance for "bodily "Fungi" means any type or form of fungus, "fungi in' ry~ or "property dem�g�". arising out ofhe e including mu|d or mi|dew and any myco1o«ins. �ngi or bacbari� i»cideDt". ia �ub��t to � im it as spores, scents or by-products produced or Fungi and Bacteria Liability Aggregate L ' described in Paragraph D. of this endorsement. released by fungi. This provision does not apply to any "fungi" or "Fungi or bacteria incident" means an incident bacteria that ere, are on, or are contained in, a which would not have nccurred, in whole or in good or product ' intended for bodily pert, but for the actuo|, alleged or threatened consumption. inhalation of, ingestion of, contact with, D. The following are added to Part D. Liability and exposure to, existence of, or presence of, any "fungi" or bacteria on or within a building or ��i�mN ��m�� mm��m� |n�ur�m�� structure, including its contento, regardless of 1. The Fungi And Bacteria Liability Aggregate whether any other camse, event, material or Limit shown in the Schedule of this product contributed concurrently or in any endorsement is the most we will pay for all sequence to such injury or damage. 891-1130 06 09 Includes copyrighted materials of Insurance Services Offices, Inc Page 1 of 1 9,601 the Docu aHanover Insurance Group_ AVENUES BUSINESSOWNERS DECLARATION BUSINESSOWNERS AMENDED DECLARATIONS EFFECTIVE 06/25/2016 NUMBER 01 32 AGENCY EXPRESS SUPERSEDES ANY PREVIOUS DECLARATIONS BEARING THE SAME NO. FOR THIS POLICY PERIOD 2-X AMENDED SALE/CONTENTS LIMITS Policy Number Policy Period Coverage is Provided in the Agency Code From To OD6-A003878-03 06/25/2016 06/25/2017 MASSACHUSETTS BAY INSURANCE COMPANY 190282000 . Named Insured anci Address Agent TRIANGLE UROLOGY ASSOCIATES, 868-635-976 ATTN: DAVIN MOORE &JOHNSON AGENCY 205FRAS|ER ST. CL HANOVER CSC DURHAM, NC 27704 PO BOX 178G7 RALEIGH, NC 27619 NAMED INSURED ENDORSEMENT TRIANGLE UROLOGY ASSOCIATES, ATTN: DAVIN PA; CRABTREE REALTY, LLC; ROBERT W. ANDREWS; NIALL J. BUCKLE Y: SAMUEL F. HUANG; JAY H. KIM; ROBERT WILLIAM REAGAN, JR. Form 391-1015 (5-00 Date Issued: 05/18/2016 MORTGAGEE Payment Type: cusTSEnVCTR'o|nEc7BILL 9,602 DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 Medical Mutuar ^ PROTECTING OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,extend, or alter the coverage afforded by the policies listed below. INSURED: Triangle Urology Associates PA 205 Frasier St Durham,NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh,NC 27609 TYPE OF INSURANCE: Claims-Made Professional Liability POLICY NUMBER: PG113371 RETROACTIVE DATE: March 1, 1978 ( POLICY PERIOD: FROM: January 1,2016;12:01 A.M. TO: January 1,2017;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 Date: October 29,2015 Authori et •epresentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM0901NC(06/08) OF NORTH CAROLINA SPRATLT DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 Medical Mutual- PROTECTING OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,extend,or alter the coverage afforded by the policies listed below. INSURED: Robert William Andrews,MD 205 Frasier St Durham,NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh,NC 27609 TYPE OF INSURANCE: Claims-Made Professional Liability POLICY NUMBER: PG113371 RETROACTIVE DATE: August 1, 1985 POLICY PERIOD: FROM: January 1,2016;12:01 A.M. TO: January 1,2017;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 Date: October 29,2015 Authori e •epresentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM090INC(06/08) OF NORTH CAROLINA SPRATLT DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 d'A‘ Medical Mutuar PROTECTLNG OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,extend,or alter the coverage afforded by the policies listed below. INSURED: Niall John Buckley,MD 205 Frasier St Durham,NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh,NC 27609 TYPE OF INSURANCE: Claims-Made Professional Liability POLICY NUMBER: PG113371 RETROACTIVE DATE: July 1, 1991 ( POLICY PERIOD: FROM: January 1,2016;12:01 A.M. TO: January 1,2017;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 Date: October 29,2015 Authori es •epresentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM0901NC(06/08) OF NORTH CAROLINA SPRATLT DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 "N„ Medical Mutual- PROTECTINE;OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,extend,or alter the coverage afforded by the policies listed below. INSURED: Jay Han Kim,MD 205 Frasier St Durham,NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh,NC 27609 TYPE OF INSURANCE: Claims-Made Professional Liability POLICY NUMBER: PG113371 RETROACTIVE DATE: July 8, 1996 ( POLICY PERIOD: FROM: January 1,2016;12:0] A.M. TO: January 1,2017;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 / Date: October 29,2015 Authori ea 'epresentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM0901NC(06/08) OF NORTH CAROLINA SPRATLT DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 Medical Mutual' PROTECTING OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,extend,or alter the coverage afforded by the policies listed below. INSURED: Edward Ross Houser, II,MD 205 Frasier St Durham,NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh,NC 27609 TYPE OF INSURANCE: Claims-Made Professional Liability POLICY NUMBER: PG113371 RETROACTIVE DATE: July 19,2010 ( POLICY PERIOD: FROM: January 1,2016;12:01 A.M. TO: January 1,2017;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 / Date: October 29, 2015 Authori es epresentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM0901NC(06/08) OF NORTH CAROLINA SPRATLT DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 Medical Mutual- - PROTECTINC OCR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,extend,or alter the coverage afforded by the policies listed below. INSURED: Samuel Fong-Yin Huang, MD 205 Frasier St Durham,NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh,NC 27609 TYPE OF INSURANCE: Claims-Made Professional Liability POLICY NUMBER: PG113371 RETROACTIVE DATE: September 3,2002 ( POLICY PERIOD: FROM: January 1,2016;12:01 A.M. TO: January 1,2017;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 / Date: October 29,2015 Authori e' 'epresentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM0901NC(06/08) OF NORTH CAROLINA PRAM DocuSign Envelope ID: 58340D10-53F7-460D-9D47-DA2ED9BEB980 s‘, Medical Mutual PROTECTINC OUR PROFESSAON CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,extend,or alter the coverage afforded by the policies listed below. INSURED: Jason R Rothman, MD 205 Frasier St Durham,NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh,NC 27609 TYPE OF INSURANCE: Claims-Made Professional Liability POLICY NUMBER: PG113371 RETROACTIVE DATE: August 1,2009 7- / POLICY PERIOD: FROM:January 1, 2016;12:01 A.M. TO: January 1,2017;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 / Date: October 29, 2015 Authori el •epresentative Certificate Holder: (. MEDICAL MUTUAL INSURANCE COMPANY PM090 INC(06/08) OF NORTH CAROLINA SPRATLT