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2016-411-E DSS - KAH Care, L.L.C. dba Right at Home - in-home aide services
MMI■ DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 Contract#68-2017 KAI-I Care, L.L.C. dba Right at Home CONTRACT # 68-2017 Fiscal Year Begins Julyl, 2016 Ends June 3,0, 2017_ NORTH CAROLINA ORANGE COUNTY IN-HOME AIDE PROVIDER SERVICES AGREEMENT THIS AGREEMENT, is made and entered into this 1 day of July, 2016 by and between Orange County, North Carolina for and on behalf of the Orange County Department of Social Services and the Orange County Department of Aging (the "County"); and KAH Care, L.L.C. dba Right at Home (the "Contractor") whose federal tax identification number or Social Security Number is: _ WITNESSETH: For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby contracts for the services of the Contractor, and the Contractor agrees to provide the services to the County in accordance with the terms of this Agreement. 1. Contract Documents: This Agreement consists of this document as well as each of the documents listed below as indicated (collectively referred to as the "Contract Documents"). If the word "Yes" appears beside the title of the contract document at the time both parties execute this Agreement, then that document is included as part of this Agreement. If the word "No" appears beside the title of the contract document at the time both parties execute this Agreement, then that document is not included as part of this Agreement. Each of the Contract Documents made part hereof are attached hereto and incorporated herein by reference to the same: TITLE OF CONTRACT DOCUMENT YES/NO (I) The General Terms and Conditions(Attachment A) YES (2) The Scope of Work, services, and rate(Attachment B) YES (3) Federal Drug Free Workplace &Nondiscrimination Certification (Attachment C) YES (4) Conflict of Interest Policy(Attachment D) YES (5) No Overdue Taxes Certification (Attachment E) YES (6) Certification Regarding Lobbying(Attachment G) YES (7) Certification Regarding Debarment(Attachment H) YES (8) Certification Regarding Transportation (Attachment J) YE'S (9) State Certifications (Attachment M) YES (10) Outcomes & Reporting(Attachment N) YES 1 Rev, 6'16 .411■11■ DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 Contract#68-20 17 KAH Care, L.L.C. dba Right at Home (11) Contract Determination Questionnaire YES 2. Precedence Among Contract Documents: In the event of a conflict between or among the terms of the Contract Documents and this Agreement, the terms of this Agreement shall control. In the event of a conflict between or among the terms of the Contract Documents, then the Contract Documents with the highest relative precedence shall prevail. The order of precedence shall be the order of documents as listed in Section 1, above, with Attachment A having precedence over Attachment B and so forth. If there are multiple Contract Amendments, the most recent amendment shall have the highest precedence and the oldest amendment shall have the lowest precedence. 3. Effective Period: This Agreement shall be effective from July 1, 2016 through June 30, 2017. 4. Contractor's Duties: The Contractor shall provide the services to the County described in Attachment B in accordance with the approved rate as described in Attachment B, Scope of Work, and shall meet the requirements set forth in Attachment N, Outcomes and Reporting. 5. County's Duties: The County shall pay the Contractor in the manner and in the amounts specified in the Contract Documents, (a) The total amount paid by the County to the Contractor under this Agreement for the provision of services to the Department of Social Services shall not exceed: $415,647. This amount consists of $415,647 in Federal, State and County funds (CFDA # ), $0 (source of other funds if applicable). (b) The total amount paid by the County to the Contractor under this Agreement for the provision of services to the Department on Aging shall not exceed: $75,000. This amount consists of $75,000 in Federal, State and County funds (CFDA # _), $0 (source of other funds if applicable), (c) There are no matching requirements from the Contractor. LI (d) The Contractor's matching requirement is $ , which shall consist of: 1 In-kind ___ Cash Cash and In-kind P1 Cash and/or In-kind The contributions from the Contractor for matching requirements for the provision of services to the Department of Social Services shall be sourced from non-federal funds. 6. Reporting Requirements: Contractor shall comply with audit requirements as described in N.C.G.S. § 143C-6-22 & 23 and OMB Circular A-133 and shall disclose all information required by 42 USC 455.104, or 42 USC 455.105, or 42 USC 455.106. 7. Payment Provisions: Payment shall be made in accordance with the Contract Documents as described in the Scope of Work, Attachment B. 8. Contract Administrators: All notices permitted or required to be given by one Party to the other and all questions about the contract from one Party to the other shall be addressed and delivered to the other Party's Contract Administrator. The name, post office address, street address, telephone number, fax number, and email address of the Parties' respective initial Contract Administrators are set 2 Rev, 6 16 DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 Contract#68-2017 KAH Care,L.L.C. dba Right at Home out below. Either party may change the name, post office address, street address, telephone number, fax number, or email address of its Contract Administrator by giving timely written notice to the other Party. For Services Performed on Behalf of the Department of Social Services: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS Renee Bynum, Adult Services Supervisor Renee Bynum, Adult Services Supervisor Orange County Department of Social Services Orange County Department of Social Services P.O. Box 8181 113 Mayo Street Hillsborough,NC 27278 Hillsborough,NC 27278 (919)245-2881 (919) 644-3005 bynumgco.oratige.ric.us For Services Performed on Behalf of the Department on Aging: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS Janice Tyler, Director Janice Tyler, Director Orange County Department on Aging Orange County Department on Aging 2551 Homestead Road 2551 Homestead Road Chapel Hill,NC 27516 Chapel Hill, NC 27516 (919)968-2071 jtvleri),co.orange.nc,us For the Contractor: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS Kenneth Helmuth Kenneth Helmuth Right at Home Right at Home 105 W. Corbin Street, Suite 203 105 W. Corbin Street, Suite 203 Hillsborough,NC 27278 Hillsborough,NC 27278 919-241-5292 Office 919-500-0130 Cell ken(krandch.com 9. No Assignment or Sub-Contract: Contractor shall not sub-contract out any of the services provided for in this Agreement or make any assignment of this Agreement (including rights to payments) without the prior written Consent of the County as specified more fully in Attachment A, General Terms and Conditions. 10. Supplementation of Expenditure of Public Funds: The Contractor assures that funds received pursuant to this contract shall be used only to supplement, not to supplant, the total amount of federal, state and local public funds that the Contractor otherwise expends for contract services and related programs. Funds received under this contract shall be used to provide additional public funding for such services; the funds shall not be used to reduce the Contractor's total expenditure of other public funds for such services. 3 Rev. 6/16 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 Contract#60'2017 KAB Care, LL[.dho Right atBomo 11. Disbursements: As a condition of this contract, the Contractor acknowledges and agrees to make disbursements in accordance with the following requirements: (a) Implement adequate internal controls over disbursements; (b) Pre-audit all vouchers presented for payment to dcteiiiiine: • Validity and accuracy of payment • Payment due date • Adequacy of documentation supporting payment • Legality of disbursement (c) Assure adequate control of signature stamps/plates; (d) Assure adequate control of negotiable instruments; and (e) Implement procedures to insure that account balance is solvent and reconcile the account monthly. 12. Outsourcing to Other Countries: The Contractor certifies that it has identified to the County all jobs related to the contract that have been outsourced to other countries, if any. The Contractor further agrees that it will not outsource any such jobs during the term of this contract without providing notice to the County. 13, Federal Certifications: Individuals and Organizations receiving federal funds must ensure compliance with certain certifications required by federal laws and regulations. The contractor is hereby complying p/itbCcdificutiona regarding Nondiscrimination, Drug-Free Workplace Requirements, Environmental Tobacco Smoke, Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions, and Lobbying. These assurances and certifications are to be signed by the contractor's authorized representative. 14. Relationship of the Parties: Contractor is an independent contractor of the County. Contractor represents that it has or will secure, at its own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees of or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized or permitted under state and local law to perform such services. It is further agreed by Contractor that it shall obey all State and Federal statutes, rules and regulations which are applicable to prnisions of the services called for herein. Neither Contractor nor any employee of the Contractor shall he deemed an officer, employee or agent of the County. 15. Termination: This Agreement may be terminated as specified in Attachment A, General Terms And Conditions. 16. Insurance Requirements: Contractor shall obtain, at its sole expense, all insurance as required in Attachment A, General Terms And Conditions. 17. Indemnification: Contractor 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 Contractor in accordance with Attachment A, General Terms And Conditions. It is the intent of this Section that Contractor indemnify County to the full extent permitted by law. 18. Entire Agreement: The parties have read this Agreement, including the Contract Documents, 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. 4 Rev. 6 16 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 Contract#68-2017 KiH Care, L.L.C. dba Right at Home 19. Interpretation: When the context in which words are used in this Agreement indicates that such is the intent, words shall in the singular number shall include the plural and vice versa. The masculine gender shall include the feminine and neuter. IN WITNESS WHEREOF, the County and the Contractor have been first duly authorized, have executed and entered into this Agreement as of the day and year first above written. KAH C DBA RIGHT AT HOME ^'~' `—`` 7/18/2016 BY: uF2928*C-7,' -- SiOpature Date Ken Helmuth owner Printed Name Title OBAN 641NTIV: NORTH CAROLINA p*tfSm.� 7/20/2016 � By: \ 06.319_44.8.7-55E-4-77... / — ---- Bonnie 13. Hammersley, County Manager Date 5 Rev. 6/16 DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 ATTACHMENT A GENERAL TERMS AND CONDITIONS Orange County Department of Social Services and Department on Aging Relationships of the Parties the County or the Contractor,receiving services or benefits under this contract shall be deemed an incidental Independent Contractor: The Contractor is and shall be beneficiary only. deemed to be an independent contractor in the performance of this contract and as such shall be wholly responsible for Indemnity and Insurance the work to be performed and for the supervision of its employees. The Contractor represents that it has, or shall Indemnification: The Contractor agrees to indemnify and secure at its own expense, all personnel required in hold harmless the County and any of their officers, agents performing the services under this agreement. Such and employees,from any claims of third parties arising out employees shall not be employees of, or have any or any act or omission of the Contractor in connection with individual contractual relationship with the County. the performance of this contract. Subcontracting: The Contractor shall not subcontract any Insurance: During the term of the contract,the Contractor of the work contemplated under this contract without prior at its sole cost and expense shall provide commercial written approval from the County. Any approved insurance of such type and with such terms and limits as subcontract shall be subject to all conditions of this may be reasonably associated with the contract. As a contract. Only the subcontractors specified in the contract minimum, the Contractor shall provide and maintain the documents are to be considered approved upon award of following coverage and limits: the contract. The County shall not be obligated to pay for (a) Worker's Compensation - The contractor shall any work performed by any unapproved subcontractor. provide and maintain Worker's Compensation The Contractor shall be responsible for the performance of Insurance as required by the laws of North all of its subcontractors. Carolina, as well as employer's liability coverage with minimum limits of$500,000.00,covering all Assignment: No assignment of the Contractor's of Contractor's employees who are engaged in any obligations or the Contractor's right to receive payment work under the contract. If any work is sublet,the hereunder shall be permitted. However, upon written Contractor shall require the subcontractor to request approved by the issuing purchasing authority, the provide the same coverage for any of his County may: employees engaged in any work under the (a) Forward the Contractor's payment check(s) contract. directly to any person or entity designated by the (b) Commercial General Liability - General Contractor, or Liability Coverage on a Comprehensive Broad (b) Include any person or entity designated by Form on an occurrence basis in the minimum Contractor as a joint payee on the Contractor's amount of$1,000,000.00 Combined Single Limit. payment check(s). (Defense cost shall be in excess of the limit of In no event shall such approval and action obligate the liability.) County to anyone other than the Contractor and the (c)Automobile Liability Insurance: The Contractor Contractor shall remain responsible for fulfillment of all shall provide automobile liability insurance with a contract obligations, combined single limit of$500,000.00 for bodily injury and property damage; a limit of Beneficiaries: Except as herein specifically provided $500,000.00 for uninsured/under insured motorist otherwise,this contract shall inure to the benefit of and be coverage; and a limit of$25,000,00 for medical binding upon the parties hereto and their respective payment coverage. The Contractor shall provide successors. It is expressly understood and agreed that the this insurance for all automobiles that are: enforcement of the terms and conditions of this contract, (a) owned by the Contractor and used in the and all rights of action relating to such enforcement, shall performance of this contract; be strictly reserved to the County and the named (b) hired by the Contractor and used in the Contractor.Nothing contained in this document shall give performance of this contract; and or allow any claim or right of action whatsoever by any (c) Owned by Contractor's employees and other third person. It is the express intention of the County used in performance of this contract("non- and Contractor that any such person or entity, other than owned vehicle insurance"). Non-owned General Terms and Conditions—(06/16) Page 1 of 5 DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 vehicle insurance protects employers when employees use their personal vehicles for Termination Without Cause: The County may tenninat work purposes. Non-owned vehicle this contract without cause by giving 30 days writte insurance supplements, but does not notice to the Contractor. replace,the car-owner's liability insurance. Termination for Cause: If, through any cause, th The Contractor is not required to provide and maintain Contractor shall fail to fulfill its obligations under thi. automobile liability insurance on any vehicle—owned, contract in a timely and proper manner, the County sha I hired, or non-owned -- unless the vehicle is used in the have the right to terminate this contract by giving writte performance of this contract. notice to the Contractor and specifying the effective dat'- (d) The insurance coverage minimums specified in thereof. In that event,all finished or unfinished deliverabl7 subparagraph(a) are exclusive of defense costs. items prepared by the Contractor under this contract shal (e) The Contractor understands and agrees that the at the option of the County, become its property and th insurance coverage minimums specified in Contractor shall be entitled to receive just and equitabl subparagraph (a) are not limits, or caps, on the compensation for any satisfactory work completed on sue Contractor's liability or obligations under this contract. materials,minus any payment or compensation previousl (f) The Contractor may obtain a waiver of any one or more made. Notwithstanding the foregoing provision, th of the requirements in subparagraph (a) by Contractor shall not be relieved of liability to the Count demonstrating that it has insurance that provides for damages sustained by the County by virtue of th protection that is equal to or greater than the coverage Contractor's breach of this agreement,and the County ma and limits specified in subparagraph (a). The County withhold any payment due the Contractor for the purpos. shall be the sole judge of whether such a waiver of setoff until such time as the exact amount of damage. should be granted. due the County from such breach can be determined. I (g) The Contractor may obtain a waiver of any one or more case of default by the Contractor, without limiting an of the requirements in paragraph(a)by demonstrating other remedies for breach available to it,the County ma that it is self-insured and that its self-insurance procure the contract services from other sources and hol, provides protection that is equal to or greater than the the Contractor responsible for any excess cost occasioneit coverage and limits specified in subparagraph(a). The thereby. The filing of a petition for bankruptcy by th County shall be the sole judge of whether such a Contractor shall be an act of default under this contract. waiver should be granted. (h) Providing and maintaining the types and amounts of Waiver of Default: Waiver by the County of any defaull insurance or self-insurance specified in this paragraph or breach in compliance with the terms of this contract is a material obligation of the Contractor and is of the the Provider shall not be deemed a waiver of an.' essence of this contract. subsequent default or breach and shall not be construed to (i) The Contractor shall only obtain insurance from be modification of the terms of this contract unless state o companies that are authorized to provide such to be such in writing, signed by an authorizer coverage and that are authorized by the Commissioner representative of the County and the Contractor awl of Insurance to do business in the State of North attached to the contract. Carolina.All such insurance shall meet all laws of the State of North Carolina. Availability of Funds: The parties to this contract agree . (j) The Contractor shall comply at all times with all lawful and understand that the payment of the sums specified it terms and conditions of its insurance policies and all this contract is dependent and contingent upon and subjecl lawful requirements of its insurer, to the appropriation, allocation, and availability of fund. (k) The Contractor shall require its subcontractors to for this purpose to the County. comply with the requirements of this paragraph. (I) The Contractor shall demonstrate its compliance with Force Majeure: Neither party shall be deemed to be i the requirements of this paragraph by submitting default of its obligations hereunder if and so long as it I. certificates of insurance to the County before the prevented from performing such obligations by any act o Contractor begins work under this contract. war,hostile foreign action,nuclear explosion,riot,strikes, civil insurrection,earthquake,hurricane,tornado,or othe Transportation of Clients by Contractor:The contractor catastrophic natural event or act of God. will maintain Insurance requirements if required as noted under Article 7 Rule R2-36 of the North Carolina Utilities Survival of Promises: All promises,requirements,term Commission. conditions, provisions, representations, guarantees, ari!I warranties contained herein shall survive the contrac Default and Termination expiration or termination date unless specifically provide General Terms and Conditions—(06/16) Page 2 of DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 otherwise herein, or unless superseded by applicable that comply with all applicable federal, state and Federal or State statutes of limitation. local laws, regulations, and rules. Intellectual Property Rights (b) Duty to Report: The Contractor shall report a suspected or confirmed security breach to the Copyrights and Ownership of Deliverables: All local Department of Social Services Contract deliverable items produced pursuant to this contract are the Administrator within twenty-four(24)hours exclusive property of the County. The Contractor shall not after the breach is first discovered, provided that assert a claim of copyright or other property interest in the Contractor shall report a breach involving such deliverables. Social Security Administration data or Internal Revenue Service Data within one(1) hour after Federal Intellectual Property Bankruptcy Protection the breach is first discovered. Act: The Parties agree that the County shall be entitled to all rights and benefits of the Federal Intellectual Property (c) Cost Borne by Contractor: If any applicable Bankruptcy Protection Act,Public Law 100-506,codified federal, state, or local law, regulation or rule at 11 U.S.C. 365 (n) and any amendments thereto. requires the Contractor give written notice of a security breach to affected persons,the Contract Compliance with Applicable Laws shall bear the cost of the notice. Compliance with Laws: The Contractor shall comply Trafficking Victims Protection Act of 2000: with all laws, ordinances, codes, rules, regulations, and The Contractor will comply with the requirements of licensing requirements that are applicable to the conduct of Section 106(g) of the Trafficking Victims Protection Act its business, including those of federal, state, and local of 2000, as amended (22 U.S.C. 7104) agencies having jurisdiction and/or authority. By executing this Agreement Provider certifies that Executive Order#24: It is unlawful for any vendor, Provider has not been identified, and has not utilized contractor, subcontractor or supplier of the state to make the services of any agent or subcontractor, on the list gifts or to give favors to any state employee. For created by the State Treasurer pursuant to G.S. 147- additional information regarding the specific 86.58. requirements and exemptions, contractors are encouraged to review Executive Order 24 and G.S. Sec. 133-32. Title VI,Civil Rights Compliance: In accordance with Federal law and U.S. Department of Agriculture (USDA) Confidentiality and U.S, Department of Health and Human Services (HHS) policy, this institution is prohibited from Confidentiality: Any information, data instruments, discriminating on the basis of race, color,national origin, documents, studies or reports given to or prepared or sex age or disability. Under the Food Stamp Act and assembled by the Contractor under this agreement shall be USDA policy, discrimination is prohibited also on the kept as confidential and not divulged or made available to basis of religion or political beliefs. any individual or organization without the prior written approval of the County.The Contractor acknowledges that Equal Employment Opportunity: The Contractor shall in receiving,storing,processing or otherwise dealing with comply with all federal and State laws relating to equal any confidential information it will safeguard and not employment opportunity:. further disclose the information except as otherwise provided in this contract. Health Insurance Portability and Accountability Act (HIPAA): The Contractor agrees that, if the County Oversight determines that some or all of the activities within the scope of this contract are subject to the Health Insurance Access to Persons and Records: The State Auditor shall Portability and Accountability Act of 1996, P.L. 104-91, have access to persons and records as a result of all as amended ("HIPAA"), or its implementing regulations, contracts or grants entered into by State agencies or it will comply with the HIPAA requirements and will political subdivisions in accordance with General Statute execute such agreements and practices as the County 147-64,7. Additionally,as the State funding authority,the may require to ensure compliance. Department of Health and Human Services shall have access to persons and records as a result of all contracts or (a) Data Security: The Contractor shall adopt and grants entered into by State agencies or political apply data security standards and procedures subdivisions. General Terms and Conditions -(06/16) Page 3 of 5 DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 I subcontractors,complies with the requirements of Article 2 Record Retention: Records shall not be destroyed, of Chapter 64 of the NC General Statutes. purged or disposed of without the express written consent of the Division. State basic records retention policy Miscellaneous 1 , requires all grant records to he retained for a minimum of five years or until all audit exceptions have been resolved, Choice of Law: The validity of this contract and any of i s whichever is longer. If the contract is subject to federal tei His or provisions, as well as the rights and duties oft le policy and regulations,record retention may be longer than parties to this contract, are governed by the laws of No ih five years since records must be retained for a period of Carolina. The Contractor, by signing this contract, agrels three years following submission of the final Federal and submits,solely for matters concerning this Contract, is Financial Status Report, if applicable, or three years the exclusive jurisdiction of the courts of North Caroli la following the submission of a revised final Federal and agrees, solely for such purpose, that the exclusi 'e Financial Status Report. Also, if any litigation, claim, venue for any legal proceedings shall be Orange Count , negotiation, audit, disallowance action, or other action North Carolina. The place of this contract and a 1 involving this Contract has been started before expiration transactions and agreements relating to it, and their sit s of the five-year retention period described above, the and forum,shall be Orange County,North Carolina,whe e records must be retained until completion of the action and all matters,whether sounding in contract or tort,relating ' resolution of all issues which arise from it,or until the end the validity, construction, interpretation,and enforceme t of the regular five-year period described above,whichever shall be determined. is later. The record retention period for Temporary Assistance for Needy Families (TANF) and MEDICAID Amendment: This contract may not be amended orally r and Medical Assistance grants and programs must be by performance. Any amendment must be made in writte retained for a minimum of ten years. form and executed by duly authorized representatives 'f the County and the Contractor. Warranties and Certifications Severability: In the event that a court of compete t Date and Time Warranty: The Contractor warrants that jurisdiction holds that a provision or requirement of th's the product(s) and service(s) furnished pursuant to this contract violates any applicable law, each such provisio , contract("product"includes,without limitation,any piece or requirement shall continue to be enforced to the extent t of equipment,hardware,firmware,middleware,custom or is not in violation of law or is not otherwise unenforceabl 1 commercial software,or internal components,subroutines, and all other provisions and requirements of this contrast and interfaces therein) that perform any date and/or time shall remain in full force and effect. data recognition function, calculation, or sequencing will support a four digit year format and will provide accurate Headings: The Section and Paragraph headings in thes date/time data and leap year calculations. This warranty General Terms and Conditions are not material parts of th shall survive the termination or expiration of this contract. agreement and should not be used to construe the meanin,' thereof Certification Regarding Collection of Taxes: G.S. 143- 59.1 bars the Secretary of Administration from entering Time of the Essence: Time is of the essence in th- into contracts with vendors that meet one of the conditions performance of this contract. of G.S. 105-164.8(b)and yet refuse to collect use taxes on sales of tangible personal property to purchasers in North Key Personnel: The Contractor shall not replace any o Carolina. The conditions include: (a) maintenance of a the key' personnel assigned to the performance of thi. retail establishment or office; (b) presence of contract without the prior written approval of the County. representatives in the State that solicit sales or transact The term "key personnel" includes any and all person. business on behalf of the vendor; and (c) systematic identified as such in the contract documents and any othe exploitation of the market by media-assisted, media- persons subsequently identified as key personnel by th, facilitated, or media-solicited means. The Contractor written agreement of the parties. certifies that it and all of its affiliates (if any) collect all required taxes. Care of Property: The Contractor agrees that it shall b, responsible for the proper custody and care of any propert E-Verify furnished to it for use in connection with the performance of this contract and will reimburse the County for loss o•, Pursuant to G.S. 143-48.5,the undersigned hereby certifies or damage to, such property. At the termination of thi. that the Contractor named below, and the Contractor's contract, the Contractor shall contact the County fo General Terms and Conditions---(06/16) Page 4 of 1 DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 instructions as to the disposition of such property and shall comply with these instructions. Orange County Living Wage: Orange County is committed to providing its employees with a living wage Travel Expenses: Reimbursement, if provided in this and encourages agencies to which it provides funding to Agreement, to the Contractor for travel mileage, meals, pursue the same goal. The County's living wage hourly lodging and other travel expenses incurred in the standard, as adopted by the Orange County Board of performance of this contract shall not exceed the rates County Commissioners annually, can be found in the established in County policy. Orange County Budget Ordinance. To the extent possible, Orange County recommends that the Contractor and all Sales/Use Tax Refunds: lf eligible,the Contractor and all subcontractors provide a living wage, as defined in this subcontractors shall: (a) ask the North Carolina section, to their employees. Department of Revenue for a refund of all sales and use taxes paid by them in the performance of this contract, Signatures: This Agreement together with any pursuant to G.S. 105-164.14; and (b) exclude all amendments or modifications may be executed refundable sales and use taxes from all reportable electronically. All electronic signatures affixed hereto expenditures before the expenses are entered in their evidence the intent of the Parties to comply with Article reimbursement reports. 11A and Article 40 of North Carolina General Statute Chapter 66. Advertising: The Contractor shall not use the award of this contract as a part of any news release or commercial advertising. General Terms and Conditions--(06/16) Page 5 of 5 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 ATTACHMENT B SCOPE OF WORK Orange County Department of Social Services and Orange County Department on Agi Federal Tax Id.or SSN Contruct# A. CONTRACTOR INFORMATION 1. Contractor Agency Name: K/\If Care,L1.C. dba Right at Home 2. /fuiffe/en(from Contract Administrator Information in General Contract: Address Telephone Number: _ Fax Number: Email: 3. Name of Program(s): In-Home Services 4. Status: ( )Public ( ) Private, Not for Profit (X) Private, For Profit 5. Contractor's Financial Reporting Year July 1, 2016 through June 30, 2017 B. Explanation of Services to be provided and to whom (include SIS Service Code): The Contractor ill provide employees to perform in-home services for the Department of Social Services' clients and the Department on Aoing's clients, at the level, amount and frequency specified by the social worker in the In-Home Aide Services Plan. (SIS Code 042) The Contractor will provide Level II Home Management and Level III Personal Care. The Contractor is required tQmeet all goals and outcomes listed in Attachment N. C. Rate per unit of Service(define the unit): 1. If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart) A maximum allowable rate of$2].00/hour. of which the Contrtor must pay the In Home Aide at least the County's Livin Wage(currently $13.15 per/hi). The County has increased the standard fixed rate to compepsate Contractor for any amount above Federal Minimum Wage. _ 2.Negotiated County Rate. D. Number of units to be provided:__., E. Details of Billing process and Time Frames; The County will reimburse the Contractor for services described in this contract up to tohe budgetary limits of the contract allotment, The County will reimburse the Contractor uzarate of$21.00/hour for approypd services providedFor reimbursement,the Contractor must submit an original and two copies of an invoice by the fifth of the month for the •n:cedin_ month's expenditures to the designated County Administrator. All invoices for the provision of services tn the Department ofQpial Services shall be submitted to the Administrator for said Department. All invoices for the provision of ser s to the Contract-Scope of Work(06/04) Page lof\ ~ DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 Department ktcd to the Administrator for said Department. The Count will reimburse the Contractor monthly upon receipt of a complete and correctly filed report. F. Area to be served/Delivery site(s): 0rao_c Coun DocuSigned by: Nancy Coston, Social Service Director 7/21/2016 1 (Date Submitted) DILIAA-6t, I'll(tr o"cu»mned»': Janice Tyler,Dept. on Aging Director 7/22/2016 (Date Submitted) o"""»m""^»':thLAAA, (Signature of Contractor) 7/18/2016 (Date Submitted) Contract-Scope of Work(06/04) Page 2of 2 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 ATTACHMENT C CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS AND CERTIFICATION REGARDING NONDISCRIMINATION Orange County Department of Social Services and Department on Aging I. By execution of this Agreement the Contractor certifies that it will provide a drug-free workplace by: A. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the Contractor's workplace an d specifying thracdonsdhu1vi|| hc <akrnugubzot employees for violation of such prohibition; B. Establishing a drug-free awareness program to inform employees about: (I) The dangers of drug abuse in the workplace; (2)The Contractor's policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; C. Making it a requirement that each employee be engaged in the performance of the agreement be given a copy of the statement required by paragraph(A); D. Notifying the employee in the statement required by paragraph(A)that, as a condition of employment under the agreement, the employee will: (l) Abide bythe terms of the statement; and (2)Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction; E. Notifying the County within ten days after receiving notice under subparagraph (D)(2) from an employee or otherwise receiving actual notice of such conviction; F. Taking one of the following actions, within 30 days of receiving notice under subparagraph (I))(2),with respect to any employee who is so convicted: (I)Taking appropriate personnel action against such an employee, up to and including termination; or (2) Requiring such employee to participate satisfactorily' in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; and Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (A), (B), (C), (D), (E), and (F). Federal Certification- Drug-Free Workplace 61 Nondiscrimination rev,0O-2Ul5 Page 1 of 1 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 IL The site(s) for the performance of work done in connection with the specific agreement are listed below: . (Street address) (City, county, state, zip code) 2. (Street address) (City, county, state, zi code) Contractor will inform the County of any additional sites for perfomiance of*ockuudertbbugrecnoent. False certification or violation of the certification shall be grounds for suspension of payment, suspension or termination of grants, or government-wide Federal suspension or debarment 45 C.F.R. Section 0I'510. Section 4 CFR Part 85, Section 85.615 and 86.620. CERTIFICATION REGARDING NONDISCRIMINATION The Vendor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI m[the Civil Rights Act uf |984 (Pl. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b)Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 D.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §8610}'6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 9[ hl0), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §83601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i) the requirements of any other nondiscrimination statutes which may apply to this Agreement, DocuSigned by: 54AA. M%LAAk¢k~ owner Signature Title KAH care' LLC 7/18/2016 Agency/Organization Date (Certification s should be same as Contract signature.) Federal Certificatio Drug-Poe Workplace&Nondiscrimination rev, 06-2015 Page 2 of 2 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 ATTACHMENT D CONFLICT OF INTEREST POLICY Orange County Department of Social Services The Board of Directors/Trustees or other governing pemoox, ufficur», employees or agents are to avoid any conflict of interest, even the appearance of a conflict of interest. The Organization's Board of Directors/Trustees or other governing body, officers, staff and agents are obligated to always act in the best interest of the organization.This obligation requires that any Board member or other governing person, officer, employee or agent, in the performance of Organization duties, seek only the furtherance of the Organization mission. At all times, Board members or other governing persons, officers, employees or agents, are prohibited from using their job title, the Organization's name or property, for private profit or benefit. A. The Board members or other governing persons, officers, cmp\oyeco, or agents of the Organization should neither solicit nor accept gratuities, favors, or anything of monetary value from current or potential contractors/vendors, persons receiving benefits from the Organization or persons who may benefit from the actions of any Board member or other governing person, officer, employee or agent. This is not intended to preclude bona-fide Organization fund raising- activities. Q. A Board or other governing body member may, with the approval of Board or other governing body, receive honoraria for lectures and other such activities while not acting in any official capacity for the Organization. Officers may, with the approval of the Board or other governing body, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay. Employees may, with the prior written approval of their supervisor, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay. If a Board or other governing body member, officer, employee or agent is acting in any official capacity, honoraria received in connection with activities relating to the Organization are to be paid to the ()r0unizo1ion. C. No Board member or other governing person, officer, omp|oyco, or agent of the Organization shall participate in the selection, award, or administration of a purchase or contract with a vendor where,to his knowledge,any of the following has a financial interest in that purchase or contract: I. The Board member or other governing person, officer,employee, or agent; 2. Any member of their family by whole or half blood, step or personal relationship or relative-in-law; 3. An organization in which any of the above is art officer, director,or employee; 4. A person or organization with whom any of the above individuals is negotiating or has any arrangement concerning prospective employment or contracts. O. Duty to Disclosure -- Any conflict of interest, potential conflict of int noyt, or the appearance of a conflict of interest is to be reported to the Board or other governing body or one's supervisor immediately. E. Board Action -- When a conflict of interest is relevant to a matter requiri action by the Board of Directors/Trustees or other governing body, the Board member or other governing person, officer, employee,or agent(person(s)) must disclose the existence of the conflict of interest and be given the opportunity to disclose all material facts to the Board and members of Conflict nf Interest Po|icy(N5/\5) Page 1 of 3 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 committees with governing board delegated powers considering the possible conflict of interest. After disclosure of all material facts,and a0eranydioousyionwithdbepersoo,he/sheohaU |cave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon. The remaining board or committee members shall decide if a conflict of interest exists. In addition, the person(s)shall not participate in the final deliberation or decision ,euardiogthe mu�erunder consideration and shall leave the n�e�ingduhngthe discussioo~of and vote of the Board of Directors/Trustees or other governing body. F. Violations of the Conflicts of Interest Policy -- If the Board of Directors/Trustees or other governing body has reasonable cause to believe a member, officer, employee or agent has failed to disclose actual or possible conflicts of inierest, it shall inform the person of the basis for such belief and afford the person an opportunity to explain the alleged failure to disclose. If, after hearing the person's response and after making further investigation as warranted by the circumstances, the Board of Directors/Trustees or other governing body determines the member, officer, employee or agent has failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective action. G. Record of Conflict -- The minutes of the governing board and all committees with board delegated powers shall contain: 1. The names of the persons who disclosed or otherwise were found to have an actual or possible conflict bT interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. Z. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. Approved by: /74 ,„ 6����^ Name f i i *mitre-"" rgail cial 0 Date Pu�x2of3 ConOk�ofin�r Interest DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 NOTARIZED CCNFLICT OF INTEREST POLICY State of North Carolina County of Orange � , Notary Public for said County and State, certify that limenilej-1,1 A L_Iit jrikurVi personally appeared before me this VIA\--i\ti CAve._ L-LL and by that anThori 5,' duly given and as the act of the corporation, affirmed that the foregoing Conflict of Interest Policy was adopted by the Board of Directors/Trustees or other governing body in a meeting held on the {~ doyof "_ __. _ \ � Sworn to and subscribed belye,,m. this .day � � �! \ \=' „,�/' /' ('�Dii o|) ' ~ `�, °� ...... ~~ �� � --__\ ' umo/v PuN� "� Notary P/@1u\, .^~ o,m ComNv rw` es I My Commission expires 20\21r"/ � Conflict of interest Policy(06/15) Page 3of] DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487. at Right � � Home 4905 Pine Cone Drive, SUITE 2 | P31S,237233J I vmmw.raxdok.00m In Homo Cam A Anakatnnce DURHAM, NC 27707 | F81g237.2152 | infv@rahgoh,cam ATTACHMENT E OVERDUE' TAXES Orange County Department of Social Services Contract#68-2017 KAR Care, LL.C, dba Right at Home Date: June 30, 2016 To: Orange County Department of Social Services Certification: I certify that the KAH Care, EEC does not have any overdue tax debts, as defined by N.C.G.S. 105-243.1 ', at the federal, State, or local level. | further understand that any person who makes a false statement in violation ofN.C.G3. 143C-6-23(c) is guilty ofa criminal offense punishable as provided by NC.G.S, 143C-10'l(h). Sworn Statement: Kenneth Helmuth being duly sworn says that he is the Board Chair of KAH Care, 1,1,,C of Durham in the State of North Carolina; and that the foregoing certification is true,accurate and complete to the best of our knowledge and was made and subscribed by him I also acknowledge and understand that any misuse ot'State funds will be reported to the appropriate authoritics for further action ) --, , '� Sworn the day of the date olsaid certilication, `xuwv,// � ��y L�nmisuiun �x����� - � ( ~` �~ =^°` �xpvoy ,.,ouuy �/g�o/ '�&^��.�� -- � �` • : ~^ '// ,?`' ,^ G.S. 105-243.1 deflnes:Overdue tax debt, —Any part ofa tax debt that remains unpaid 90 day or more afte the notice offimal assessment was mailed to the taxpayer. File term does not include a tax debt,however, if the taxpayer entered into an installment agreement for the tax debt under u,S, |V5-2]7 within vm days after the notice olOnul assessment was mailed and has not f'aiIcLI to make any payments due under the installment agreement" DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 ATTACHMENT G CERTIFICATION REGARDING LOBBYING Orange County Department of Social Services and Department on Aging Certification for Contracts. Grants, Loan and Cooperatic Agreements The undersigned certifies, to the best of his or her knowledge and belief,that: (1) No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any Federal, state or local government agency, a Member of Congress, a Member of the General Assembly, an officer or employee of Congress, an officer or employee of the General Assembly, an employee of a Member of Congress, or an employee of a Member of the General Assembly in connection with the awarding of any Federal or state contract, the making of any Federal or state grant, the making of any Federal or state loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal or state contract, grant, loan, or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any Federal, state or local government agency, a Member of Congress, a Member of the General Assembly, an officer or employee of Congress, an officer or employee of the General Assembly, an employee of a Member of Congress, or an employee of a Member of the General Assembly in connection with the awarding of any Federal or state contract, the making of any Federal or state grant,the making of any Federal or state loan,the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal or state contract, grant, loan, or cooperative agreement,the undersigned shall complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers(including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients sbu|l certify and disclose accordingly. (4) This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Notwithstanding other provisions of federal 0NdB Circulars-CFR Title 2 Grants and Agnammanto. Part 200, costs associated with the following activities are unallowable: Paragraph A. (1) Attempts to influence the outcomes of any Federal, State, or local election, referendum, initiative, or similar procedure,through in kind or cash contributions, endorsements, publicity, or similar activity; (2) Establishing, administering, contributing to, or paying the expenses of a political party, campaign, political action committee, or other organization established for the purpose of influencing the outcomes of elections; , (3) Any attempt to influence: (i)The introduction of Federal or State legislation; or(ii) the enactment or modification of any pending Federal or State legislation through communication with any member or employee of the Congress or State legislature (including efforts to influence State or local Federal Certification— Lobbying(06/15) Page 1 of} DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 officials to engage in similar lobbying activity), or with any Government official or employee in connection with a decision to sign or veto enrolled legislation; (4) Any attempt to influence: (i)The introduction of Federal or State legislation; or(ii)the enactment or modification of any pending Federal or State legislation by preparing, distributing or using publicity or propaganda, or by urging members of the general public or any segment thereof to contribute to or participate in any mass demonstration, march, rally, fundraising drive, lobbying campaign or letter writing or telephone campaign; or (5) Legislative liaison activities, including attendance at legislative sessions or committee hearings, gathering information regarding legislation, and analyzing the effect of legislation, when such activities are carried on in support of or in knowing preparation for an effort to engage in unallowable lobbying. The following activities as enumerated in Paragraph B are excepted from the coverage of Paragraph A: Paragraph B. (1) Providing a technical and factual presentation of information on a topic directly related to the performance of a grant, contract or other agreement through hearing testimony, statements or letters to the Congress or a State legislature, or subdivision. member, or cognizant staff member thereof, in response to a documented request(including a Congressional Record notice requesting testimony or statements for the record at a regularly scheduled hearing) made by the recipient member, legislative body or subdivision, or a cognizant staff member thereof; provided such information is readily obtainable and can be readily put in deliverable form; and further provided that costs under this section for travel, lodging or meals are unallowable unless incurred to offer testimony at a regularly scheduled Congressional hearing pursuant to a written request for such presentation made by the Chairman or Ranking Minority Member of the Committee or Subcommittee conducting such hearing. (2) Any lobbying made unallowable by subparagraph A(3)to influence State legislation in order to directly reduce the cost, or to avoid material impairment of the organization's authority to perform the grant, contract, or other agreement. (3) Any activity specifically authorized by statute to be undertaken with funds from the grant, contract, or other agreement. Paragraph C. (1) When an organization seeks reimbursement for indirect costs. total lobbying costs shall be separately identified in the indirect cost rate proposal, and thereafter treated as other unallowable activity costs in accordance with the procedures of subparagraph B.(3), (2) Organizations shall submit, as part of the annual indirect cost rate propoxa|, a certification that the requirements and standards of this paragraph have been complied with. (3) Organizations shall maintain adequate records to demonstrate that the determination of costs as being allowable or unallowable pursuant to this section complies with the requirements of this Circular. (4) Time logs, calendars, or similar records shall not be required to be created for purposes of complying with this paragraph during any particular calendar month when: (I)the employee engages in lobbying(as defined in subparagraphs(a)and (b)) 25 percent or less of the employee's compensated hours of employment during that calendar month,and(2) within the preceding five- year period,the organization has not materially misstated allowable or unallowable costs of an nature, including legislative lobbying costs. When conditions (11)and(2) are met, organizations are not required to establish records to support the allowability of claimed costs in addition to records already required or maintained. /\|ou, when conditions(1) and (2) are met,the absence of time logs, ouleodam, or similar records will not serve as a basis for disallowing costs by contesting estimates of lobbying time spent by employees during a calendar month, Federal Certification Lobbying(0615) Pu2c2of2 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 (5) Agencies mhaKex�h|ixhprocedures for rosmhingin advance, i000nnuko1ou*�b0�IB, any ` ' significant questions or disagreements concerning the interpretation or application of this section. Any such advance resolution shall be binding in any subsequent settlements, audits or investigations with respect to that grant or contract for purposes of interpretation of this Circular; provided, however, that this shall not be construed to prevent a contractor or grantee from contesting the lawfulness of such a determination. Paragraph D. Executive lobbying costs. Costs incurred in attempting to improperly influence either directly or indirectly, an employee or officer of the Executive Branch of the Federal Government to give consideration or to act regarding a sponsored agreement or a regulatory matter are unallowable. Improper influence means any influence that induces or tends to induce a Federal employee or officer to give consideration or to act regarding a federally sponsored agreement or regulatory matter on any basis other than the merits of the matter. DocuSigned by: . �UL ' � c`uvnouu~ owner .°'w43um8.28*G-7— Title KAH care. LLC 7/18/2016 - - Agency/Organization o�� �cuoy�jr�an�� d Date (Certification signature should be same as Contract signature) Federal Certification—Lobbying 15) pnAe3of3 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 ATTACHMENT H CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION-LOWER TIER COVERED TRANSACTIONS Orange County Department of Social Services and Department on Aging Instructions for Certifioation l. By signing and submitting this proposal,the prospecti tier is providing the certification set out below. Z. The certification in this clause is a material representation of the fact upon which reliance was placed when this transaction was entered into, If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government,the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. 3. The prospective lower tier participant will provide immediate written notice to the person to which the proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtai ing a copy of those regulations. 5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter any lower tier covered transaction with a person who is debarred, suspended, determined ineli ible or voluntarily excluded from participation in this covered transaction unless authorized by the department or agency with which this transaction originated. 6. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion- Lower Tier Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency of which it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List. 8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. Federal Certification-Debarment(06/15) Page | ofl DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 9. Except for transactions authorized in pa 5 of these instructions, if a paicipant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension, and/or debarment. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions (1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Where the prospective lower tier participant is unable to certi1 to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. DocuSigned by: owner _ Signature - Title KAH care' LLC 7/18/2016 Agency/Organization Date (Certification signature should be same as Contract signature.) Page 2 f2 Federal Cc�ifice1ioo' Debarment(06/15) a�e n DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 ATTACHMENT J CERTIFICATION REGARDING TRANSPORTATION Orange County Department of Social Services and Orange County Department on Aging By execution of this Agreement the Contractor certifies that it will provide safe client transportation by: I. Insuring that all drivers (including employees, contractors, contractor's employees, and volunteers) shall be at least 18 years of age; 2. Insuring that all drivers (including employees, contractors, contractor's employees, and volunteers) shall be licensed to operate the specific vehicle used in transporting clients in accordance with Chapter 20-7 of the General Statutes of North Carolina and the Division of Motor Vehicle requirements; 3. Insuring that all vehicles transporting clients shall have at least the minimum level of liability insurance appropriate for the type of vehicle as defined by Article 7, Rule R2-36 of the North Carolina Utilities Commission; 4. Insuring that the contractor shall have written policies and procedures regarding how drivers handle and report client emergencies and/or vehicle crashes involving clients to contractor and how contractor notifies the County Department of Social Services; 5. Insuring that no more than one quarter of one percent of all trips be missed by the contractor during the course of the contract period; (Medicaid only) 6. Insuring that that no more than five percent (5%) of trips should be late for recipient drop off to their appointment per month; (Medicaid only) 7. Contractor will maintain records documenting the following (County may require contractor to provide): a. Valid current copies of Drivers License for all drivers; b. Current valid Vehicle Registration, for all vehicles transporting clients; c. Driving records for all drivers for the past three years and with annual updates; d. Criminal Background checks through North Carolina Law Enforcement or NCIC prior to employment and every three years thereafter; e. Alcohol and Drug Testing policy to meet the Federal Transit Authority guidelines. 8. Disclosing, at the outset of the contract, upon renewal and upon request, any criminal convictions or other reasons for disqualifications from participation in Medicare, Medicaid or by:Title XX programs (signature on this form confirms this statement). DocuSigned At6/44, owner .1. • DF27034C(... Signature Title KAH care, LLC 7/18/2016 Agency/Organization Date (Certification signature should be same as Contract signature.) Transportation Certification(06/16) Page 1 of I DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 ATTACHMENT M STATE AND LOCAL CERTIFICATION Contractor Certifications Required by North Carolina Law orange County Department of Social Services Instructions The person who signs this document should read the text of the statutes listed below and consult with counsel and other knowledgeable persons before signing. • The text of Article 2 of Chapter 64 of the North Carolina General Statutes can be found online at: http://wwv/.nugu.ataUo.nc.us{Enuc{cdLcg,iulauimn/S{o1utco/PDF/By/\rtic|c/CbapTer 64//\rtiv|e_2.pdf • The text o[(}.D. !U5'l64.8(b) can he found online at: http://vvv/vv.nu8u,state.nc.ux/Fnuc1rdLe (o|aoinn/Stotu<ex/PDF/Rv3ection/[hu tcr |05/GS 105'164.8.pdf • The text of(J.8. l43'40.5 (8.L. 20l3'4lW, x. 2{d)) can be found online at: http://www.ncga.state.nc.us/Sessions/2013/Bills/House/PDF/H786v6.pdf • The text of G.S. 143-59.1 can be found online at: http://*ww.ncgu.statc.nc.us/EouctcdLcgis|ution/8tututen/P[}F/0ySeution/Chnp{cr 143/G3_143'59.1.pdf • The text of G.S. 143-59.2 can be found online at: http://vvvvvv.ncgo.stute.uo.ua/£muotedLegislu1 8ccdon/Chuptcr 143/{3S .143-59,2.pd[ • The text ofG.S. 147'33.95(g)(S.L. 2013-418' s. 2. (e)) can be found online at: v/.ncga.s1ateIc'us/5eoo[mno/2013/Bi\|a/Hmnao/PZ}P/U786v6.pdf • The text of Orange County Living Wage Contractor Policy which is attached to this document. Certifications (1) Pursuant to G.S. 143-48.5, the undersigned hereby certifies that the Contractor named below, and the Contractor's oubcootractnca, complies with the requirements of Article 2 of Chapter 64 of the NC General Statutes, including the requirement for each employer with more than 25 employees in North Carolina to verify the work authorization of its employees through the federal E-Verify system." E-Verify System Link: WW`v.uocis.gov Local government is specifically exempt from Article 2 of Chapter 64 of the North Carolina Genera Statutes. However, local government is subject to and must comply with North Carolina General Statute V153/\-99.1., which states in part as follows: Counties Must Use F-Verify. - Each county shall register and participate in F-Verify to verify the work authorization of new employees hired to work in the United States. (2) Pursuant to G.S. 843-59.1(h), the undersigned hereby certifies that the Contractor named below is not an "ineligible Contractor"as set forth in G.S. 143-59.1(a) because: (a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or Contractor Certifications Required by North Carolina Law Pne 1 of 1 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 more of the conditions of U.S. 105-164.8(b); and (b) [check one of the following boxes] F� Neither bcCo�mcNzuor �� ofhaN�|��sk� � or � o '�� hm- ' __ country" uu set forth inG.S. [43'5g.l(o) (2)after December 31, 208l; mr I l The Contractor or one ot'its affiliates has incorporated or reincorporated in a -tax haven count'.`1 " as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is not t e principal market for the public trading of the stock of the corporation incorporated in the t~1` haven country. (3) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers, director., or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapt.lr 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 yea s immediately prior to the date of the bid solicitation. . (4) Theundeoi8nedbere6vccrtificxfudbertbut: (a) He or she is a duly authorized representative of the Contractor named below; (b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of t e Contractor; and (o) He or she understands that any person who knowingly submits a false certification in response to ti e requirements of G.S. 143'59.1and '59.2 shall be guilty of a Class I felony. (5) Pursuant to the Orange County Living Wage Contractor's Policy: (a) The undersigned certifies that the Contractor pays the employees who perform services under this cmo(ractlu living wage (in Orange County currently $13.15 peribr.) Check here I if contractor pays enup|oyo(s performing under this contract a living wage. If Contractor does not pay employees a living wage, v/hat is t e wage that employees performing services under this contract paid -- — -- -- -- | KAH care' LLC Signed by. Coo 7/18/2016 Signature of Contractor's Authorized Agent Date Ken Helmuth owner Pr in r`s Authorized Agent C w~ zu^o^�u���� Title o Di rector o r of operations Signature nfWitness Title Pam Williamson 7/20/2016 Printed Name ofWitness Date The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and d, e this document immediately thereafter. Contractor Certifications Required by North Carolina Law Page 2n 2 1 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 Section I: General Government and Administration Policy 10.0: Living Wage Contractor Policy Reviewed by: County Attorney/County Manager Approved by: County Manager Original Effective Date: April 21, 2016 Revisions: Policy Statement It is the policy of Orange County to ensure its employees, and all individuals who provide services for Orange County, are paid a living wage. Purpose To encourage all vendor and contractors to pay a living wage to all employees who perform work pursuant to a contract with Orange County. Applicability Applies to all Orange County contracts and purchases. Policy 10.1 Living Wage lO.l.\ Orange County is committed to providing its employees with a living wage and encourages all contractors and vendors doing business with Orange County to pursue the same goal. Orange County's living wage is $12.76 per hour. To the extent possible, Orange County recommends that contractors and vendors seeking to do business with Orange County provide a living wage to their employees. 10.1.2 Prior to final execution of a contract with Orange County all contractors and vendors seeking to do business with Orange County shall submit to the County's representative a statement indicating whether those employees who will perform work on the Orange County contract are paid at least the living wage amount set out above. If such employees do not make at least the living wage amount set out above the contractor or vendor shall indicate in the statement the actual amount paid to such employees. For bid projects this statement should be submitted as part of the bid packet. This policy may be reviewed annually and updated as needed by the Manager's Office Contractor Certifications Required by North Carolina Law Page 3 of 3 DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 ATTACHMENT N OUTCOMES AND REPORTING Orange County Department of Social Services and Orange County Department on Aging By signing and submitting this document, the Contractor certifies that it agrees to the following: 1. The Contractor agrees to participate in program, fiscal and administrative monitoring and/or audits, making records and staff time available to Federal, State and County staff. 2. The Contractor agrees to take necessary steps for corrective action, as negotiated within a corrective action plan, for any items found to be out of compliance with Federal, State, and County laws, regulations, standards and/or terms of the Contract. 3. The Contractor agrees that continuation of and/or renewal of this Contract is contingent on meeting the following requirements. The Contractor agrees to: A. ADo`vUzeCouotytoconop|etctheusncosoncu1o{cucholieuLTbeCouotyvvU| oonup|ctcon [n' Home Aide Service Plan as part of the assessment. The Countywill provide the In-Home Aide Service Plan to the Contractor prior to the start of service. The County will update the In-Home Aide Service Plan as needed. B. Provide employees to perform in-home services for the County's clients, at the level, amount and frequency specified by the social worker in the In-Home Aide Service Plan. C. Assure that employees meet the competency requirements for the level(s)of service provided. The Contractor will provide verification, upon request, that the selected employee has been properly licensed and trained and is qualified to perform assigned tasks. D. Select and assign qualified employees to clients according to the clients' needs and the employees' abilities and experience, The Contractor agrees to honor requests made by the County for a change In assignment. E. Fulfill all employer financial obligations. F. In a timely manner, provide the County with information on significant changes in the clients' conditions or situations. G. Assure that the client is treated with dignity and respect, assist in protecting the client's assets and possessions and circumstances. H. Allow aides to provide transportation,within reason, for both medical and personal reasons. I. Provide care at Level II as appropriate to the needs of the client. J. Complete, for employees serving Level II clients, at least a quarterly on site visit to the home of at least one client the employee is serving. K. Maintain all financial and program records for a period of three years from the date of final payment under this agreement for inspection by the County, the Area Agency on Aging and the Comptroller General of the United States, or any of their duly authorized representatives. If any claim, litigation, negotiation, audit or other action involving the Contractor's records has been started before the expiration of the three-year period, the records must be retained until completion of the action and resolution of all issues that arise from it. L. Monthly contact and annual on-site visits with the County. The Contractor agrees to client contact per Home and Community Care Block Grant guidelines. M. Protective Service In-Home Aide requests are to be staffed within 24 hours and the hours to be worked arc to be strictly adhered to. Referral acceptance by the Contractor is conditional on worker availability. The Contractor will notify the County within two hours if the request cannot be honored. N. Provide backup service when a client's usual In-Home Aide is unavailable. Outcomes (06/04) Page 1 of I ......■ DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 O. High Risk In-Home Aide Service requests are to be staffed within five days. All other requests are to be filled within ten working days of the request. P. Changes in the service hours are to be made by the County. Requests for changes may he made by the Contractor, but are not finalized until notification is given by the County. Q. The Contractor will immediately notify the County when Protective Services Cases are not staffed, when In-Home Aide workers are absent, and/or when any of the following occur: a. The client dies. b. The client enters a rest home, nursing home, or hospita . c. The client moves from the original address on the request. d. The client refuses to accept the services or to comply with care requirements. e. There are significant factors that affect the client or significant changes in a client's situation. DocuSigned by: "`~~—~' owner `--`^45A*oF2*284C' ---- ' ' — -- Signature Title KAH care' LLC 7/18/2016 Agency/Organization Date (Certification signature should be same as Contract signature.) Po�n2of2 Outcomes (06/04) DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 KAHCA-1 OP ID:AC AC©RQ DATE.(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/1212016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Agency,Inc. NAME: Tony McCroskey, CIC Granite Insurance A 9 y, PHONE FAX 56 North Main Street s.alc,No.Exth 828-396-3342 lAJC,No):828 496-3834 Post Office Drawer 620 E-MAIL Granite Falls,NC 28630-0620 ADDRESS:tmccroskey@graniteinsurance.com Tony McCroskey,CIC INSURER(S)AFFORDING COVERAGE NAIC tf INSURER A:Manchester Specialty Programs INSURED KAH Care, LLC .._._._.....-INSURER E..... INSURER ....... .. DBA Right at Home suRE B Synergy Insurance Company 12773 4905 Pine Cone Drive, Suite 2 INSURER C: Durham, NC 27707 INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL sunk- POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 AMAGIEf ID RENTED CLAIMS-MADE ', OCCUR MAC502518200 02/1612016 02116/2017 PREMISESgEaoccurrence; S 100,000 MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY s 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER 1 GENERAL AGGREGATE S 3,000,000 PRO- POLICY 1 JECT I LOC I PRODUCTS-COMP/OP AGG S 3,000,000 '...OTHER., AUTOMOBILE LIABILITY ,. COMBINED SINGLE LIMIT S 1,000,000 Ea accidence A ANY AUTO MAC502518200 02/16/2016 02/16/2017 BODILY INJURY(Per person) S _ ALL OWNED .._._....... SCHEDULED _.. -. .......... .. -...._. .. .. ...._, AUTOS NON-OWNED__ AUTOS BODILY INJUURY(Per aocident) 5 PROPERTYDAMAGE S UTOS (Per accident) X HIRED AUTOS X AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER - B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA WC100-000481-116 05/05/2016 05/05/2017 E L EACH ACCIDENT s 1,000,000 OFFICER/MEMBER EXCLUDED? --""-" "----"--"-- (Mandatory inNH) EL,DISEASE-EA EMPLOYEE S 1,000,000 ff yes describe under DESCRIPTION OF OPERATIONS below E ,DISEASE-POLICY LIMIT S 1,000,000 A Property Section MAC502518200 02/1612016 02/16/2017 A Theft MAC502518200 Client Pr 10,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ORANG-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Department of ACCORDANCE WITH THE POLICY PROVISIONS. Social Services PO Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough,NC 27278 /f 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 C ^81 *02/22/ 16~MAC5O25102'00^511354745 ~D/8° ORIG IMAGE COPY 0410446 GREAT AMERICAN E&S |NS CO Administrative Offices CG 74 00 (Ed. 07 01) no/cwxmmm G«mEmAm ER2CAN | Cincinnati on4am2-4m1 Policy No. MAC 502'51 '82 - 00 INSURANCE GROUP | mxx6onnoupx ' GENERAL LIABILITY COVERAGE PART DECLARATIONS PAGE • NAMED INSURED: KAH CARE, LLC POLICY PERIOD: 02/ 16/ 16 to 02/16/ 17 LIMITS OF INSURANCE: General Aggregate Limit (Other Than Products - Completed Operations) $ 3, 000, 000 Products - Completed Operations Aggregate Limit $ 3, 000, 000 Personal and Advertising Injury Limit $ 1 , 000 , 0 O 0 Each Occurrence Limit $ 1 , UOD DOO Damage to Premises Rented to You Limit $ 1 0 O 000 Any One Premises Medical Expense Limit 5, OOO Any One Person FORM OF BUSINESS: TOTAL ESTIMATED PREMIUM: $ 1 , 5 7 2 Products/Completed Operations All Other $ INCL $ INCL SCHEDULE OF LOCATIONS: LOCATION 1 : 4905 PINE CONE DRIVE, STE 2 ; DURHAM, NC 27707 CODE NUMBER: PREMIUM BASIS: CLASSIFICATION: PER CG7401 Products/Completed Operations All Other Exposure: Exposure: Rate: Rate: Premium: Premium: FORMS AND ENDORSEMENTS applicable to this Coverage Part and made a part of this Policy at the time of issue are listed on the attached Forms and Endorsements Schedule CG 88 01 (11/85). CG 74 00 (Ed. 07/01) PRO (Page 1 of 1) DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 C °81 ^D2/22/1O~MAC5O25182'O0^511354745 ^ O/8 ~ ORIG IMAGE COPY 0410446 GREAT AMERICAN E&S INS CO Administrative Offices 3o�Ewxmm° CG �� �2 �»u����&�yERYC/�� om,/nneuooe2ox (Ed. 12/09) INSURANCE GROUP 513 369 5000 ph Policy No. MAC 502-51 -82 - 00 ABUSE OR MOLESTATION COVERAGE FORM DECLARATIONS PAGE NAMED INSURED: KAH CARE, LLC POLICY PERIOD: O2/ 1G/ 18 to 02/ 10/ 17 LIMITS OF INSURANCE: Aggregate Limit $ 1 , 0 0 0, 0 0 0 Each Abuse Limit $ 1 , 0 0 0 , 0 0 0 DESCRIPTION OF BUSINESS: Form of Business ( ) Individual ( ) Joint Venture ( ) Partnership ( X ) Organization (Other Than Partnership or Joint Venture) READ YOUR POLICY CAREFULLY, OPTIONAL COVERAGES ARE PROVIDED BY PREMIUM INSERTION. Premium Abuse or Molestation Coverage $ I N C L TOTAL ADVANCE PREMIUM $ 3 8 1 Premium shown is payable: $ }NCL at inception; FORMS AND ENDORSEMENTS Applicable to this Coverage Part and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule CG 88 01 (11/85). CG 82 82 (Ed. 12/03) (Page 1 of 1) = DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 C ^S1 ^02/22/ 16°MAC5825182'00^511354745 ^ O/B ° ORIG IMAGE COPY 0410440 GREAT AMERICAN E&S INS CO Administrative Offices CG 87 13 (Ed. 06/14) �o/��xo�mm `�"^E����MEx�C'�� oo"/�m/ox �5oo2 INSURANCE GROUP mommoowvh Policy No. MAC 502-51 -82 - 00 PROFESSIONAL LIABILITY COVERAGE PART DECLARATIONS PAGE This is a Claims-Made Policy. Please Read the Entire Policy Carefully. NAMED INSURED: KAH CARE, LLC POLICY PERIOD: 02/ 16/ 16 to O2/ 1G/ 17 LIMITS OF INSURANCE: Aggregate Limit $ 3, 0 0 0 , 0 0 0 Each Act, Error, or Omission $ 1 , 0 0 0 , 0 0 0 RETROACTIVE DATE This insurance does not apply to any act, error, or omission which occurs before the Retroactive Date, if' any, shown here: 02/ 16 / 1 4 (enter date or "none" if does not apply) DESCRIPTION OF BUSINESS: Form of Business ( ) Individual ( ) Joint Venture ( ) Partnership ( X ) Organization (Other Than Partnership or Joint Venture) TOTAL ADVANCE PREMIUM $ 1 , 58 3 . Premium shown is payable: $ |NCL at inception; FORMS AND ENDORSEMENTS Applicable to this Coverage Part and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule CG 88 01 (11/85). DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 4, SYNERGY my URANCC COMPANY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE RENEWAL AGREEMENT Insurer: PRODUCER: Agent 15 Synergy Insurance Company Granite Insurance Inc. 217 South Tryon Street PO Box 620 Charlotte, NC 28202-3201 Granite Falls, NC 28630 (Carrier Code: 66998) Carrier Policy #: WC100-000481-116 Carrier Prior Policy #: WC100-000481-115 1. The Insured: KAH Care, LLC Right at Home Mailing Address: Ken Helmuth 4905 Pine Cone Drive, Suite 2 Durham, NC 27707 File #: 100000000481116 Fein: Other workplaces not shown above: Type of Business: Limited Liability Co SEE SCHEDULE OF OPERATIONS Risk ID: 2 . The policy period is from 12:01 a.m. on 5/05/2016 to 12 :01 a.m. on 5/05/2017 at the insured' s mailing address. 3 . A. Workers Compensation Insurance: Part One of the policy applies to the 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 .A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1, 000, 000 each accident Bodily Injury by Disease $ 1, 000, 000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15) WC000310 (04/84) WC000402 (04/84) WC000406 (08/84) WC000414 (07/90) WC000419(01/01) W0000421D(01/15) WC000422B(01/15) WC320301C(01/14) 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. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 54, 513.00 Minimum Premium $ 1, 120.00 Expense Constant 250.00 Deposit Premium .00 WC 00 00 01 A Copyright 1994 National Council on Compensation Insurance Inc. Countersigned by DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 SCHEDULE OF OPERATIONS FOR: PAGE: 1 Right at Home Carrier Policy # : WC100-000481-116 KAH Care, LLC Fein: Ken Helmuth 4905 Pine Cone Drive, Suite 2 Durham, NC 27707 OTHER WORKPLACES : KAH Care, LLC Right at Home 4905 Pine Cone Drive Eff date : 05/05/16 Suite 2 NAICS : 621610 Durham, NC 27707 DIV # : 00000 E/L Number: 0000000001 WC 00 00 01 B DocuSign Envelope ID: D246BF38-3F94-4A4B-B6B9-C4F5BAC37487 SCHEDULE OF OPERATIONS FOR: PAGE: 2 ***** PREMIUM INFORMATION FOR NC ***** Right at Home Carrier Policy # : WC100-000481-116 KAH Care, LLC Fein: Ken Helmuth 4905 Pine Cone Drive, Suite 2 Durham, NC 27707 Code Classification Payroll Rate Premium 8742 SALESPERSONS COLLECTORS 0 19, 657 . 53 . 63 124 . 00 ( 5/05/16- 2/16/17) 8810 CLERICAL OFFICE EMPLOYEES 51, 109 . 59 .26 133 . 00 ( 5/05/16- 2/16/17) 8835 NURSING-HOME HEALTH PUBLI 530, 753 .42 4 . 19 22, 239 . 00 ( 5/05/16- 2/16/17) 8742 SALESPERSONS COLLECTORS 0 5, 342 .47 . 67 36 . 00 ( 2/16/17- 5/05/17) 8810 CLERICAL OFFICE EMPLOYEES 13 , 890 . 41 . 23 32 . 00 ( 2/16/17- 5/05/17) 8835 NURSING-HOME HEALTH PUBLI 144, 246 . 58 4 . 08 5, 885 . 00 ( 2/16/17- 5/05/17) Manual Premium 28, 449 . 00 Increased Employers Liability Limits 1 .400% 398 . 00 Experience Modification - Listed below 54, 809 . 00 Schedule Debit 1 . 1000 5, 481 . 00 Standard Premium 60, 290 . 00 Premium Discount 10 . 00% 6, 027 . 00 Normal Premium 54, 263 . 00 Expense Constant 250 . 00 TERRORISM 125 . 00 CATASTROPHE 125 . 00 Annual Premium 54, 763 . 00 Experience Modifiers 1 . 9000 2/16/2016 WC 00 00 01 B