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HomeMy WebLinkAbout2017-312-E Housing - Lucia Centeno for Spanish interpretation DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 ORANGE COUNTY COUNTYWIDE INTERPRETER CONTRACT NORTH CAROLINA (15,000 OR LESS) THIS AGREEMENT, made and entered into this 1st day of July, 2017, ("Effective Date") by and between Orange County, North Carolina, a body politic and corporate organized under the laws of the State of North Carolina, (the"County"), and Lucia Centeno(the "Provider"); WITNESSETH: For the purpose and subject to the following terms and conditions hereinafter set forth, the County hereby contracts for the services of the Provider, and the Provider agrees to provide the following Interpretation Services (hereinafter referred to as "Services") to the County in accordance with the terms of this Agreement, time being of the essence. 1. Contract. This Contract consists of this document and additional documents checked below: a. For Health Department: i. n Health Department Additional Terms and Conditions ii. n Business Associates Agreement iii. I Condition of Contract Statement b. For Department of Social Services: i. n The General Terms and Conditions (Attachment A); ii. M The Scope of Work, description of services, and rate(Attachment B); iii. Federal Certification Regarding Drug-Free Workplace (Attachment C); iv. M Conflict of Interest (Attachment D); v. X No Overdue Taxes (Attachment E); vi. n Outcomes and Reporting(Attachment N) These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements or agreements. 2. Provider's Responsibilities: a. The Provider shall be qualified to interpret between English and Spanish with the client and County staff. b. Professional Conduct. The Provider shall adhere to the standards of professional conduct of an interpreter while conducting the services to include the following: i. The Provider shall relate to all County clients and staff in a respectful and professional manner. ii. The Provider will interpret the information being shared between client/family and staff as clearly as possible, without additional personal comments or biases on the topic being discussed. 1 Revised 06/16 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 iii. The provider when providing interpretation services will interpret the information as clearly as possible without changing the meaning and the intent of the conversation. iv. The Provider will interpret the information to the best of his/her ability. c. Client Confidentiality. i. The Provider acknowledges that she/he may have access to information that is confidential and provided by state and federal laws and agrees to comply with all p Y �' p Y is privacy policies, regulations, and laws as well as the Health Insurance Portability and Accountability Act(HIPAA) of 1996(P.L.104-191). ii. The Provider agrees to protect confidential information (e.g., client name, appointment type, telephone number, health information) that he/she may receive in doing business with County. The Provider should ensure proper, safe storage and protection of client information during use, and shredding/deletion of such information when it is no longer necessary for business purposes. iii. Breaches of client confidentiality will result in automatic termination of this Agreement. d. Scope of Services. i. Procedures and Guidelines Upon Acceptance of an Interpretation Assignment: 1. The Provider agrees to give at least 24 hour notice if he/she is unable to participate in a scheduled client contact. 2. The Provider will be expected to make confirmation phone calls to clients in advance of an assigned appointment, when feasible, and when the Provider is provided the information by County staff. The Provider should notify County staff as soon as possible if the client has told the Provider that he/she will not be able to make the appointment and/or if he/she needs to reschedule. These confirmation calls will not be paid for separately, but are considered part of the service when the Provider accepts an assignment for an appointment. 3. The Provider shall not have contact with County clients without County staff being present, unless specifically asked by staff to call clients to confirm or schedule appointments. It is not acceptable for the Provider to give out his/her home telephone number or cell phone number for later contact between the family and Provider. 3. County's Responsibilities. County will compensate Provider as provided in subsection 4 for interpretation services at the rate prescribed. Per hour reimbursement will begin at the time the Provider meets with County staff for the appointment and ends at the time the staff and interpreter contact is completed. There will be a minimum of one (1) hour of service for an appointment. County will reimburse the Provider for one (1) hours of interpretation service in the event of a same day cancelled appointment. That includes appointments for clients who do not show up for an appointment, and for those who cancel an appointment with less than 24 hour notice. 2 Revised 06/16 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 4. Payment for Services: The County agrees to pay at the rates specified for Services satisfactorily performed in accord with this Agreement. a. Compensation. Compensation for Services shall include all compensation due the Provider from the County for all Basic Services provided under this Agreement as specified below. i) Basic Services. The amount to be paid by the County shall not exceed Five Thousand Dollars ($5,000), to be paid at a rate of$40/hour for Interpretation Services. 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. ii) The Provider shall complete and submit the County Invoice for Payment of Interpretation Services form to County staff at the time the service is rendered. County staff will verify the information, sign and forward the form for payment of services. Any additional charges not specified herein, must be mutually agreed to in advance by County and Provider and documented in writing with a letter signed by authorized representatives for County and Provider and, subject to budgeted funds. b. For interpretation services: i) The Provider will record the start and finish time worked to the minute. After the first hour of service,payment will be calculated and paid per minute. ii) The Provider shall submit one invoice per client, unless there is a block of appointments without interruption. Without interruption means that there were no cancelled appointments and no lunch hour included. This is appropriate for a group of clients who are served for the same type of appointment, at the same location. For question, contact the departmental contact. iii) In the event of a cancelled appointment, the Provider is required to stay until relieved of duty by the individual in charge. County staff may require other interpreter-related services in place of the scheduled appointment. As stated above, the Provider may submit an invoice in the event of a broken appointment(with less than 24 hour notice). iv) If the Provider is assisting County staff with a large volume of phone calls outside of a scheduled appointment time, the Provider should complete a Call Log to submit along with an invoice describing the services performed. This type of service is paid by the minute,without a one hour minute requirement for payment. v) In the case of an unexpected closing or delayed opening (e.g., inclement weather) of the County Offices when providing interpretation services, the Provider shall not be paid for missed appointments. When in doubt, the Provider can call 732-8181 to see if county offices are open or are on a delayed schedule. When possible, the Provider is also asked to help call his/her scheduled clients to inform them of the delay or closing. 5. Term. The term of this Agreement shall be from July 1, 2017 to June 30,20018. 6. Errors and Omissions. 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 3 Revised 06/16 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the County. 7. Additional Terms and Condition. The County may have additional terms and condition that shall be provided as attachment 1, and shall be attached and are hereby incorporated by reference. 8. Precedence Among Contract Documents: In the event of a conflict between or among the terms of the Contract Documents, the terms in the Contract Document with the highest relative precedence shall prevail. The order of precedence shall be the order of documents as listed in Paragraph 1, above, with this contract document having the highest precedence then the first listed document and the last-listed document having the lowest precedence. If there are multiple Contract Amendments, the most recent amendment shall have the highest precedence and the oldest amendment shall have the lowest precedence. 9. 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. 10. Independent Contractor: The Provider shall operate as an independent Provider, and the County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated as an employee with respect to the Services performed hereunder for federal or state tax,unemployment or workers' compensation purposes. The Provider understands that neither federal, nor state, nor shall payroll tax of any kind be withheld or paid by the County on behalf of the Provider or the employees of the Provider. 11. Insurance: Provider shall obtain, at its sole expense, Professional Liability or Errors and Omissions Insurance, and any additional insurance as may 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. 12. 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. 13. 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. 14. 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. 4 Revised 06/16 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 15. 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 is or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 16. 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. 17. Non Appropriation: Provider acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County's obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non- appropriation of public funds. is IN WITNESS WHEREOF, Orange County and the Provider have signed this Agreement, effective as of the day first written above. ORANGE COUNTY PROVIDER: Lucia Centeno DocuSigned by: p--DocuSigned by: By: 1jbin,lnA. tka"mt-IrS By: bAt;it CUAI,IA,b BdturieffalaitYgley,County Manager s----E6DETIEge9748C... 200 S. Cameron St. Spanish Interpreter P.O.Box 8181 8002 Mackenzie Ct. Hillsborough,NC 27278 Durham,NC 27713 5 Revised 06/16 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 ATTACHMENT B SCOPE OF WORK Orange County Department of Social Services Federal Tax Id. or SSN Contract# A. CONTRACTOR INFORMATION 1. Contractor Agency Name: 2. If different from Contract Administrator Information in General Contract: Address Telephone Number: _ Fax Number: Email: 3. Name of Program (s): Interpreter Services 4. Status: ( ) Public ( ) Private, Not for Profit (X) Private, For Profit 5. Contractor's Financial Reporting Year July 1,2017 through June 30, 2018 B. Explanation of Services to be provided and to whom(include SIS Service Code): C. Rate per unit of Service (define the unit): 1. If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart) 2. Negotiated County Rate. $40.00/hour- Interpretation • 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 the budgetary limits of the contract allotment. The County will reimburse the Contractor at a rate of$40.00/hour for approved services provided and travel at the county rate. For reimbursement, the Contractor must submit the Orange County Department of Social Services Invoice for Payment of Interpreting Services form to the County staff at the time services are rendered. County staff will verify the information, sign the form, and forward the form to the designated County Administrator. The County will reimburse the Contractor monthly upon receipt of a complete and correctly filed report. Contract-Scope of Work(06/04) Page lof 2 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 Per hour reimbursement will begin at the time the Contractor meets with County staff for the appointment and ends when the County staff and Contractor contact is completed. There will be a minimum of 1 hour of service for an appointment. Mileage reimbursement will be for round trip from the Contractor's home or work site to the P prearranged a ointment site. F. Area to be served/Delivery site(s): _Orange County 4i DocuSigned by: p--DocuSigned by: 1561/,utk tka"mt rstui baba CWt,ln b 679 4 BoSSE477 (Signafur0e 3 or unty Authorized Person) (Sig Wdr ififractor) 7/17/2017 7/12/2017 (Date Submitted) (Date Submitted) is Contract-Scope of Work(06/04) Page 2of 2 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 is ATTACHMENT C CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS Orange County Department of Social Services 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 and specifying the actions that will be taken against employees for violation of such prohibition; B. Establishing a drug-free awareness program to inform employees about: (1) 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: (1)Abide by the 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(D)(2), with respect to any employee who is so convicted: (1) 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(06/04) Page 1 of 2 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 II. The site(s) for the performance of work done in connection with the specific agreement are listed below: 1. 113 Mayo Street (Street address) Hillsborough, Orange,NC, 27278 (City, county, state, zip code) 2. 2501 Homestead Road (Street address) Chapel Hill, Orange, NC, 27516 (City, county, state, zip code) Contractor will inform the County of any additional sites for performance of work under this agreement. 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 (Section 4 CFR Part 85, Section 85.615 and 86.620). , --DocuSigned by: CWI cMi certified Spanish Interpreter Signature --E6DEODSEFA9748C Title 7/12/2017 Agency/Organization Date (Certification signature should be same as Contract signature.) Federal Certification-Drug-Free Workplace(06/04) Page 2 of 2 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 rr ATTACHMENT D CONFLICT OF INTEREST POLICY Orange County Department of Social Services Conflict of Interest Defined: A conflict of interest is defined as an actual or perceived interest by a(Contractor/staff member/Board member) in an action that results in, or has the appearance of resulting in, personal, organizational, or professional gain. A conflict of interest occurs when an employee/Contractor/Board member has a direct or fiduciary interest in another relationship. A conflict of interest could include: ➢ Ownership with a member of the Board of Directors/Trustees or an employee where one or the other has supervisory authority over the other or with a client who receives services. ➢ Employment of or by a member of the Board of Directors/Trustees or an employee where one or the other has supervisory authority over the other or with a client who receives services. ➢ Contractual relationship with a member of the Board of Directors/Trustees or an employee where one or the other has supervisory authority over the other or with a client who receives services. ➢ Creditor or debtor to a member of the Board of Directors/Trustees or an employee where one or the other has supervisory authority over the other or with a client who receives services. ➢ Consultative or consumer relationship with a member of the Board of Directors/Trustees or an employee where one or the other has supervisory authority over the other or with a client who receives services. The definition of conflict of interest includes any bias or the appearance of bias in a decision-making process that would reflect a dual role played by a member of the organization or group. An example, for instance, might involve a person who is an employee and a Board member, or a person who is an employee and who hires family members as consultants. Employee/Contractor/Board Member Responsibilities: It is in the interest of the organization, individual staff, and Board members to strengthen trust and confidence in each other,to expedite resolution of problems, to mitigate the effect and to minimize organizational and individual stress that can be caused by a conflict of interest. Employees are to avoid any conflict of interest, even the appearance of a conflict of interest. This organization serves the community as a whole rather than only serving a special interest group. The appearance of a conflict of interest can cause embarrassment to the organization and jeopardize the credibility of the organization. Any conflict of interest,potential conflict of interest, or the appearance of a conflict of interest is to be reported to your supervisor immediately. Employees are to maintain independence and objectivity with clients, the community, and organization. Employees are called to Conflict of Interest Policy(06/04) Page 1 of 2 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 is maintain a sense of fairness, civility, ethics and personal integrity even though law, regulation, or custom does not require them. Acceptance of Gifts: Employees, members of employee's immediate family, and members of the Board are prohibited from accepting gifts, money or gratuities from the following: a. Persons receiving benefits or services from the organization; b. Any person or organization performing or seeking to perform services under contract with the organization; and c. Persons who are otherwise in a position to benefit from the actions of any employee of the organization. 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 the employee is acting in any official capacity, honoraria received by an employee in connection with activities relating to employment with the organization are to be paid to the organization. NOTARIZED CONFLICT OF INTEREST POLICY State of North Carolina County of Orange 6 N Oe' )I, (�G6 , certify that I have read the forgoing information, u•+ stand it, and t rs no onflict of interest exists in the execution of this contract. 111011/ j00101101111111. II Signature Sworn to and subscribed before me on the e22 day of , 201 17 . iy Lldi'% Q My Commission Expires: /-. ob/11 o Signature and Seal) ,�W,N{N ,pI k i% _04_ 14° NOTARY PUBLIC x U= Conflict of Interest Policy(06/04) Page 2 of 2 DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 Exhibit E Lucia Centeno 8002 MacKenzie Ct. Durham,NC 27713 To: Orange County Department of Social Services Certification: I certify that I do not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at the federal, State, or local level. I further understand that any person who makes a false statement in violation of N.C.G.S. 143-6.2(b2)is guilty of a criminal offense punishable as provided by N.C.G.S. 143-34(b). Sworn Statement: I, being duly sworn, say that I am Lucia Centeno; and that the foregoing certification is true, accurate and complete to the best of my knowledge and was made and subscribed by me. I also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for fu er a'tion. i fir / Signature Sworn to and subscribed before me on the 2 day of Gl. , 201 7. , ..(w My Commission Expires: / a, �OlV To . , Signature and Seal) or 4SCP-r R 'f'''�, -S NOTARY z PUBLIC 4 /tfiCOUI4V% DocuSign Envelope ID: C8420C15-C9C1-4CO3-B333-49D77DABC2C4 R® AC DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE ‘....----- 06/29/2017 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 NAME: Hiscox Inc PHONE FAX (A/c,No,Ext): (888)202-3007 (A/C,No): 520 Madison Avenue E-MAIL ADDRESS: contact @hiscox.com 32nd Floor INSURER(S)AFFORDING COVERAGE NAIC# ( New York,NY 10022 INSURER A: Hiscox Insurance Company Inc 10200 INSURED INSURER B: Lucia Centeno INSURER C: P.O.Box 3714 INSURER D: INSURER E; Chapel Hill NC 27515 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED — CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ _ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ (. PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Professional Liability A UDC-1775133-EO-17 07/01/2017 07/01/2018 Each Claim: $250,000 Aggregate: $250,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) gg- CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4 60.SIN I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD