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2017-413-E Aging - Senior Care of Orange County Inc. for adult day health care services
DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED [Departmental Use Only] TITLE In-Home Services FY 2017-18 ORANGE COUNTY CONTRACT UNDER $15,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this 20th day of August, 2017, ("Effective Date") by and between Orange County, North Carolina, a political subdivision of the State of North Carolina, (the "County"), party of the first part; and Senior Care of Orange County Inc. (the "Provider"), party of the second part; WITNESSETH: For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby contracts for the services of the Provider, and the Provider agrees to provide the following services to the County in accordance with the terms of this Agreement, time being of the essence: The services and/or materials (hereinafter referred to collectively as "Services") to be furnished under this Agreement are as follows: adult day care services as specified in Attachment A. The term of this agreement rendered shall be from August 20, 2017 to June 30, 2018. Provider represents and agrees that Provider is qualified to perform and fully capable of performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner to the satisfaction of the County. Provider shall be responsible for all errors or omissions, in the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the County. Provider agrees that Provider shall not sub-contract any of the services to be provided in this Agreement, nor shall Provider assign any right or responsibility granted or required by this Agreement,without the prior written approval of the County. SPECIFIC TERMS 1. Payment: The County agrees to pay at the rates specified for Services satisfactorily performed in accord with this Agreement. The amount to be paid by the County shall not exceed the lesser of $50.00 per day or six-thousand, seven-hundred dollars, ($6,700). Payment shall be made within thirty (30) days of an invoice properly submitted to County. Should Provider fail to perform its duties under the terms of this Agreement, County may, without fault or penalty, withhold any payment associated with the work to be performed until such time as said work is completed. 2. Non—waiver: Failure by County at any time to require the performance by Provider of any of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of this Non-Waiver Clause. 3. Independent Contractor: The Provider shall operate as an independent contractor and the County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider. 4. Insurance: Provider shall obtain, at its sole expense, Commercial General Liability Insurance, Automobile Insurance, Workers' Compensation Insurance, and any additional insurance as may 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 Revised 2/17 1 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing division/contra cts.php). If County's Risk Manager determines additional insurance coverage is required such additional insurance shall consist of liability, workers compensation, and sexual abuse/molestation insurance (if no additional insurance required mark N/A as being not applicable). Provider shall not commence work until such insurance is in effect and certification thereof has been received by the County's Risk Manager. 5. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable attorney's fees) arising from bodily injury, including death, to any person or persons or damage to or destruction of any property caused in whole or in part by any negligent or intentional act or omission on the part of the Provider, its agents, or assigns directly or indirectly related to the Services to be performed pursuant to this Agreement on the part of the Provider. 6. Termination: This Agreement may be terminated at any time by mutual written agreement of the parties or by the County upon written notice to the Provider. County may suspend this Agreement upon reasonable notice to the Provider. 7. Entire Agreement and Signatures: The parties have read this Agreement and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between the parties unless and until modified in writing and signed by the parties. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent of the Parties to utilize electronic signatures and the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. 8. Priority: In determining the basic services to be provided, should any documents be referenced in or attached to this Agreement, the terms of this Agreement shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. 9. Governing Law: Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies,rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php.). Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 10. Dispute Resolution: Any and all suits or actions to enforce, interpret, or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County,North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. 11. Non Appropriation: Provider acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County's Revised 2/17 2 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non-appropriation of public funds. [SIGNATURE PAGE TO FOLLOW] Revised 2/17 3 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED IN WITNESS WHEREOF,County and the Provider have signed this Agreement, effective as of the day first written above. ORANGE COUNTY PROVIDER i,---DocuSigned by: DocuSigned by: By: 13atAA/ut, l voit..YsLui By: Swa 1'5UA , rimslgu, c'�.ttxa(yge-�:eager 'Title:`^—C5B55FF72C3C4D2... 200 S. Cameron St. Senior Care of Orange County Inc P.O. Box 8181 105 Meadowlands Drive Hillsborough,NC 27278 Hillsborough, NC 27278 Revised 2/17 4 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED ATTACHMENT A SCOPE OF WORK- Soltys Adult Day Health Care/ Senior Care Inc. 1. Explanation of Services to be provided: Contractor will provide a program designed to improve the emotional and mental well-being of eligible individuals by enabling eligible individuals to interact socially, receive health monitoring, and to acquire knowledge and skills, and to provide respite for the caregivers of eligible individuals. Contractor to perform these services for the Department on Aging's clients at the level, amount and frequency specified on the Purchase of Service Authorization form. Questions should be directed to the Aging Transitions Administrator. 2. Rate per unit of Service: A maximum allowable rate of$50.00 per day per individual, of which the Contractor must pay the employees at least the County's Living Wage (currently$13.75 per hour). The County has increased the standard fixed rate to compensate the Contractor for any amount above Federal Minimum Wage. Note: The Contractor will not be reimbursed for its initial intake assessment. 3. Details of Billing process and time frames: Orange County will reimburse the Contractor for services described. The County will reimburse at a rate of$50.00 per day for approved services as stated in the Purchase of Service Authorizations approved by Department on Aging staff. For Reimbursement the Contractor must submit the invoice to the Aging Transitions Data Manager within 90 days of the date of service. Any invoice submitted after that period will not be processed. The Contractor must designate one staff person to direct any billing questions from the Data Manager. At the end of the county Fiscal year, the OCDOA will send out information and cutoff date for invoice submittal. Once that date is past, no additional invoices will be processed for the closed out year. DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED Ciient#:955852 04SENIOCARI ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD1YYTT) 07/20/2017 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 BB&T Insurance Services,Inc. PHONE Fax [Arc,No,ext):888 743-2217 (Arc,No): 8888279861 414 Gallimore Dairy Road E-MAIL Suite F ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC Greensboro, NC 27409 INSURERA:Evanston Insurance Company 35378 INSURED INSURERS,Markel Insurance Company 38970 Senior Care of Orange County Inc INSURER C: Attn Day Health Center 105 Meadowlands Dr INSURER Hillsborough, NC 27278-8181 INSURERS: 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 TYPE OF INSURANCE N RL WVD POLICY NUMBER (MMIDDIYYYY) (MMMDPIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY X SM921051 07/13/2017 07/13/2018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X CLAIMS-MADE OCCUR PRE ISE a occurrence) $50,000 X BI/PD Ded:5,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 PRO. POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY AUTOS AUTOS Per accident)} $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION MWC010610201 02/08/2017 02/08/2018 X PER OTH- AND EMPLOYERS'LIABILITY Y f N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE' E.L-EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? Y� N 7 A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below El,DISEASE-POLICY LIMIT $500,000 A Professional SM921051 07/13/2017 07/13/2018 $1,000,000 each claim Liability $3,000,000 aggregate $5,000 deductible DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Policy includes endorsement that provides Additional Insured status for any Landlord,Owner,or Property Manager of the Designated Premises or any Tradeshow or Convention Sponsor or operator or any lessor of equipment. Professional Liability-Poi.#SM921051 (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Orange County Government SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 S Cameron Street ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE ktUntall ©1988 2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 2 The ACORD name and logo are registered marks of ACORD #818510696/M18508092 JUSC DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED DESCRIPTIONS (Continued from Page 1) Professional Liability Limit#1: 1,000,000 Ded.#1: $5,000.00 Limit#2: 3,000,000 Retroactive Date:July 13, 2005 for GL and PRO Sexual Acts Liability Endorsement Limit#1: 1,000,000 Limit#2:2,000,000 **Workers Comp Information** Other States Coverage Proprietors/Partners/Executive Officers/Members Excluded: Nancy Espersen, Officer Ann Burton,Officer Dave Wilkerson,Officer SAGITTA 25.3(2014101) 2 of 2 #5185106961M18508092 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED MARKEL' WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSLR2ANCE POLICY Original Printing Issued January 20,2017 WC000001A INFORMATION PAGE Insurer. Markel Insurance Company Ten Parkway North Deerfield, IL 60015-2526 800-431-1270 >r'a�:77 -a 7 gi jrn m a�+'��� � dum:-�,...,.i, �?-4�'ad.,.. rev wF tY",r r.��d�r.o✓ r� M a.!`w fwkn S.U.�.�� ,.� �-n,ti.y.�y.�-�s 1. The Insured: individual ■Partnership Senior Care of Orange County Inc Corporation or ©Corporation Mailing address: 105 Meadowlands Dr Hillsborough, NC 27278-8500 Other workplaces not shown above:See attached Location Schedule 2. The policy period is from 02/08/2017 to 02/08/2018 at the insured's mailing address 3. A. Worker Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here: NORTH CAROLINA 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 $500,000 each accident Bodily Injury by Disease $500,000 policy limit Bodily Injury by Disease $500,000 each employee C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here: All states except those listed In Item 3A of the Information Page and the following states or territories: AZ,District of Columbia,ID,ME,MT, NJ,NY,ND,OH,OR,WA,WY,Puerto Rico and US Virgin Islands. D. This policy includes these endorsements and schedules:WC990601,WC990602,WC990603,WC000000C, WC000308,WC000404,WC000406,WC000414,WC000419,WC000421 D,WC0004228,WC000424, WC320301 C,MJWC1000,MPIL 1007 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 Code Premium Basis Rate Per Estimated Classifications No Total Estimated $100 of Annual Annual Remuneration Remuneration Premium Total Estimated Annual Premium:$1,782.00 Minimum Premium:$389.00 Expense Constant$210.00 Countersigned by WC000001 A 01987 National Council on Compensation Insurance II 111111111 111111111 0111111[I1I III 11111 111111111 1 of 24 1111 11011 11 11 1I 110111111[1 1111101 0111 1111 01 11111 007598-012071-39321687-91202017 M WC0106102-01 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WC 99 06 01 EXTENSION OF INFORMATION PAGE Worker's Compensation and Employer's Liability Policy Schedule Of Premium Information Policy Number: MWC0106102-01 Issued to: Senior Care of Orange County Inc Effective Date: 02/08/2017- 02/08/2018 Coverage Provided By: Markel Insurance Company Carrier Code: 22616 Period of Operation: 02/08/2017- 02/08/2018 State of Operation: NC Premium Basis Total Rate Per Estimated Estimated Annual $100 of Annual Code Classification Remuneration Remuneration Premium Class code Description 8868 College Professional $267,123.00 0.560 $1,496.00 Employees&Clerical Manual Premium $1,496.00 Total Manual Premium $1,496.00 9807 Employers Liability 0.800 $12.00 9848 ELL Minimum 63.000 $63.00 Subject Premium $1,571.00 Total Subject Premium $1,571.00 Modified Premium $1,571.00 9887 Schedule Rating -0.050 ($79.00) Standard Premium $1,492.00 0900 Expense Constant $210.00 9740 Terrorism 0.015 $40.00 9741 Catastrophe(other than 0.015 $40.00 Certified Acts of Terrorism) Estimated Annual Premium $1,782.00 Total Amount Due $1,782.00 2of24 ©1991 National Council on Compensation Insurance. DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WC 99 06 02 EXTENSION OF INFORMATION PAGE Worker's Compensation and Employer's Liability Policy LOCATION SCHEDULE Policy Number: MWC0106102-01 Issued to: Senior Care of Orange County Inc Effective Date: 02/08/2017 to 02/08/2018 Coverage Provided By: Markel Insurance Company Carrier Code 22616 Other workplaces not shown above: Location FEIN PHONE CODE ENTITY TYPE 1 105 Meadowlands Dr 9192452017 8052 Corporation Hillsborough,NC 27278-8500 ©1991 National Council on Compensation Insurance. 3 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WC 99 06 03 Worker's Compensation and Employer's Liability Policy Payment Schedule Policy Number: MWC0106102-01 Issued to: Senior Care of Orange County Inc Effective Date:02/08/2017 Month Payment 02/08/2017 $270.00 03/08/2017 $168.00 04/08/2017 $168.00 05/08/2017 $168.00 06/08/2017 $168.00 07/08/2017 $168.00 08/08/2017 $168.00 09/08/2017 $168.00 10/08/2017 $168.00 11/08/2017 $168.00 If you elect a payment plan,then you will be subject to installment fees for each payment ranging from$3-$10 depending on the state. If you elect electronic funds transfer,these fees will not apply. ©1991 National Council on Compensation Insurance. 4 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and PART ONE subject to all terms of this policy, we agree with you WORKERS COMPENSATION INSURANCE as follows: A. How This Insurance Applies GENERAL SECTION This workers compensation insurance applies to A. The Policy bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. This policy includes at its effective date the Information Page and all endorsements and Bodily injury by accident must occur during the schedules listed there. It is a contract of insurance policy period. between you (the employer named in Item 1 of the 2. Bodily injury by disease must be caused or Information Page)and us(the insurer named on the aggravated by the conditions of your Information Page). The only agreements relating to employment. The employee's last day of last this insurance are stated in this policy. The terms of exposure to the conditions causing or aggravating this policy may not be changed or waived except such bodily injury by disease must occur during by endorsement issued by us to be part of this the policy period. policy. B. We Will Pay B. Who is Insured We will pay promptly when due the benefits required You are insured if you are an employer named in of you by the workers compensation law. Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you C.We Will Defend are insured, but only in your capacity as an We have the right and duty to defend at our expense em-ployer of the partnership's employees. any claim, proceeding or suit against you for benefits C. Workers Compensation Law payable by this insurance.We have the right to investigate and settle these claims, proceedings or Workers Compensation Law means the workers or suits. workmen's compensation law and occupational We have no duty to defend a claim, proceeding or disease law of each state or territory named in Item suit that is not covered by this insurance. 3.A. of the Information Page. It includes any amendments to that law which are in effect during D.We Will Also Pay the policy period. It does not include any federal We will also pay these costs, in addition to other workers or workmen's compensation law, any federal amounts payable under this insurance, as part of any occupational disease law or the provisions of any claim, proceeding or suit we defend: law that provide nonoccupational disability benefits. 1. reasonable expenses incurred at our request, but D. State not loss of earnings; State means any state of the United States of America, and the District of Columbia. 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; E. Locations 3. litigation costs taxed against you; This policy covers all of your workplaces listed in 4. interest on a judgment as required by law until Items 1 or 4 of the Information Page; and it covers we offer the amount due under this insurance; all other workplaces in Item 3.A. states unless you and have other insurance or are self-insured for such workplaces. 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other 5 of 24 Ed.1-15 ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) insurance or self-insurance. Subject to any limits of workers compensation law that apply to: liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is a. benefits payable by this insurance; exhausted,the shares of all remaining insurance will b. special taxes, payments into security or other be equal until the loss is paid. special funds, and assessments payable by us under that law. F. Payments You Must Make You are responsible for any payments in excess of 6. Terms of this insurance that conflict with the the benefits regularly provided by the workers workers compensation law are changed by this compensation law including those required because: statement to conform to that law. 1. of your serious and willful misconduct; Nothing in these paragraphs relieves you of your duties under this policy. 2. you knowingly employ an employee in violation of law; PART TWO 3. you fail to comply with a health or safety law or EMPLOYERS LIABILITY INSURANCE regulation; or A. How This Insurance Applies 4. you discharge, coerce or otherwise discriminate This employers liability insurance applies to bodily against any employee in violation of the workers injury by accident or bodily injury by disease. Bodily compensation law. injury includes resulting death. If we make any payments in excess of the benefits 1. The bodily injury must arise out of and in the regularly provided by the workers compensation law course of the injured employee's employment by on your behalf, you will reimburse us promptly. you, 2. The employment must be necessary or incidental G. Recovery From Others to your work in a state or territory listed in Item 3.A. We have your rights, and the rights of persons of the Information Page. entitled to the benefits of this insurance, to recover 3. Bodily injury by accident must occur during the our payments from anyone liable for the injury. You policy period. will do everything necessary to protect those rights 4. Bodily injury by disease must be caused or for us and to help us enforce them. aggravated by the conditions of your employment. H. Statutory Provisions The employee's last day of last exposure to the conditions causing or aggravating such bodily These statements apply where they are required by injury by disease must occur during the policy law. period. 1. As between an injured worker and us,we have 5. If you are sued, the original suit and any related notice of the injury when you have notice. legal actions for damages for bodily injury by 2. Your default or the bankruptcy or insolvency of accident or by disease must be brought in the you or your estate will not relieve us of our United States of America, its territories or duties under this insurance after an injury occurs. possessions, or Canada. 3. We are directly and primarily liable to any B.We Will Pay person entitled to the benefits payable by this insurance. Those persons may enforce our We will pay all sums that you legally must pay as duties; so may an agency authorized by law. damages because of bodily injury to your employees, Enforcement may be against us or against you provided the bodily injury is covered by this Employers and us. Liability Insurance. 4. Jurisdiction over you is jurisdiction over us for The damages we will pay, where recovery is permitted purposes of the workers compensation law. We by law, include damages: are bound by decisions against you under that 1. For which you are liable to a third party by reason law, subject to the provisions of this policy that of a claim or suit against you by that third party to are not in conflict with that law. recover the damages claimed 5. This insurance conforms to the parts of the Ed.1-15 6 of 24 Copyright 2013 National Council on Compensation Insurance,Inc.Ail Rights Reserved. DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) against such third party as a result of injury to Act(30 USC Sections 801 et seq. and your employee; 901-944), any other federal workers or 2. For care and loss of services; and workmen's compensation law or other federal occupational disease law, or any amendments 3. For consequential bodily injury to a spouse, to these laws; child, parent, brother or sister of the injured employee; provided that these damages are the 9. Bodily injury to any person in work subject to direct consequence of bodily injury that arises the Federal Employers' Liability Act(45 USC out of and in the course of the injured Sections 51 et seq.), any other federal laws employee's employment by you; and obligating an employer to pay damages to an employee due to bodily injury arising out of or 4. Because of bodily injury to your employee that arises out of and in the course of employment, in the course to of those laws; or any amendments to those laws; claimed against you in a capacity other than as employer. 10. Bodily injury to a master or member of the crew of any vessel and does not cover punitive C. Exclusions damages related to your duty or obligation to This insurance does not cover: provide transportation,wages, maintenance, and cure under any applicable maritime law; 1 Liability assumed under a contract. This 11. Fines or penalties imposed for violation of exclu-sion does not apply to a warranty that federal or state law; and your work will be done in a workmanlike manner; 12. Damages payable under the Migrant and 2. Punitive or exemplary damages because of Seasonal Agricultural Worker Protection Act bodily injury to an employee employed in (29 USC Sections 1801et seq.)and under any violation of law; other federal law awarding damages for 3. Bodily injury to an employee while employed in violation of those laws or regulations issued violation of law with your actual knowledge or thereunder, and any amendments to those laws. the actual knowledge of any of your executive officers; D.We Will Defend 4. Any obligation imposed by a workers We have the right and duty to defend, at our expense, compensation, occupational disease, any claim, proceeding or suit against you for unemployment compensation, or disability damages payable by this insurance. We have the benefits law, or any similar law; right to investigate and settle these claims, 5. Bodily injury intentionally caused or aggravated proceedings and suits. by you We have no duty to defend a claim, proceeding or 6. Bodily injury occurring outside the United suit that is not covered by this insurance. We have no States of America, its territories or possessions, duty to defend or continue defending after we have and Canada. This exclusion does not apply to paid our applicable limit of liability under this bodily injury to a citizen or resident of the insurance. United States of America or Canada who is E. We Will Also Pay temporarily outside these countries; We will also pay these costs, in addition to other 7. Damages arising out of coercion, criticism, amounts payable under this insurance, as part of any demotion, evaluation, reassignment, discipline, claim, proceeding, or suit we defend: defamation, harassment, humiliation, discrimination against or termination of any 1. Reasonable expenses incurred at our request, employee, or any personnel practices, policies, but not loss of earnings; acts or omissions; 2. Premiums for bonds to release attachments and 8. Bodily injury to any person in work subject to for appeal bonds in bond amounts up to the the Longshore and Harbor Workers' limit of our liability under this insurance; Compensation Act(33 USC Sections 901 et 3. Litigation costs taxed against you; seq.), the Non-appropriated Fund 4. Interest on a judgment as required by law until Instrumentalities Act(5 USC Sections 8171 et we offer the amount due under this insurance; seq.),the Outer Continental Shelf Lands Act(43 and USC Sections 1331 et seq.), the Defense Base 5. Expenses we incur. Act(42 USC Sections 1651-1654), the Federal Coal Mine Safety and Health 7 o124 Ed.1-15 ©Copyright 2013 National Council on Compensation insurance,Inc.All Rights Reserved. DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) F. Other Insurance 2. The amount you owe has been determined with We will not pay more than our share of damages our consent or by actual trial and final judgment. and costs covered by this insurance and other This insurance does not give anyone the right to add insurance or self-insurance. Subject to any limits of us as a defendant in an action against you to liability that apply, all shares will be equal until the determine your liability. The bankruptcy or insolvency foss is paid. If any insurance or self-insurance is of you or your estate will not relieve us of our exhausted,the shares of all remaining insurance obligations under this Part. and self-insurance will be equal until the loss is paid. G, Limits of Liability PART THREE OTHER STATES INSURANCE Our liability to pay for damages is limited. Our limits A. How This Insurance Applies of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. This other states insurance applies only if one or 1 Bodily Injury by Accident. The limit shown for more states are shown in Item 3.C. of the "bodily injury by accident-each accident" is Information Page. the most we will pay for all damages covered 2. If you begin work in any one of those states after by this insurance because of bodily injury to the effective date of this policy and are not one or more employees in any one accident. insured or are not self-insured for such work, all A disease is not bodily injury by accident provisions of the policy will apply as though that unless it results directly from bodily injury by state were listed in Item 3.A. of the Information accident. Page. 2. Bodily Injury by Disease. The limit shown for 3. We will reimburse you for the benefits required by "bodily injury by disease policy limit"is the the workers compensation law of that state if we most we will pay for all damages covered by are not permitted to pay the benefits directly to this insurance and arising out of bodily injury persons entitled to them. by disease, regardless of the number of 4. If you have work on the effective date of this employees who sustain bodily injury by policy in any state not listed in Item 3.A. of the disease. The limit shown for"bodily injury by Information Page, coverage will not be afforded disease-each employee"is the most we will for that state unless we are notified within thirty pay for all damages because of bodily injury by days. disease to any one employee. Bodily injury by disease does not include B. Notice disease that results directly from a bodily injury Tell us at once if you begin work in any state listed in by accident. Item 3.C. of the Information Page. 3. We will not pay any claims for damages after we have paid the applicable limit of our PART FOUR liability under this insurance. YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered H. Recovery From Others by this policy, Your other duties are listed here. We have your rights to recover our payment from anyone liable for an injury covered by this 1. Provide for immediate medical and other insurance.You will do everything necessary to services required by the workers compensation protect those rights for us and to help us enforce law. them. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other I. Actions Against Us information we may need. There will be no right of action against us under this 3. Promptly give us all notices, demands and legal insurance unless: papers related to the injury, claim, proceeding or 1. You have complied with all the terms of this suit. policy; and 8 of 24 Ed.1-15 ®Copyright 2013 National Council on Compensation Insurance,Inc,All Rights Reserved. DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) D. Premium Payments 4. Cooperate with us and assist us, as we may You will pay all premium when due.You will pay request, in the investigation, settlement or the premium even if part or all of a workers defense of any claim, proceeding or suit. compensation law is not valid. 5 Do nothing after an injury occurs that would E. Final Premium interfere with our right to recover from others. The premium shown on the Information Page, schedules, and endorsements is an estimate. The Do not voluntarily make payments, assume final premium will be determined after this policy 6. obligations or incur expenses, except at your own ends by using the actual, not the estimated, cost. premium basis and the proper classifications and rates that lawfully apply to the business and work PART FIVE covered by this policy. If the final premium is more PREMIUM than the premium you paid to us, you must pay us A. Our Manuals the balance. If it is less, we will refund the balance to you. The final premium will not be less than the All premium for this policy will be determined by our highest minimum premium for the classifications manuals of rules, rates, rating plans and classifications. covered by this policy. We may change our manuals and apply the changes to If this policy is canceled, final premium will be this policy if authorized by law or a governmental determined in the following way unless our manuals agency regulating this insurance, provide otherwise: B. Classifications 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in Item 4 of the Information Page shows the rate and force. Final premium will not be less than the pro premium basis for certain business or work rata share of the minimum premium. classifications. These classifications were assigned 2. If you cancel, final premium will be more than based on an estimate of the exposures you would have pro rata; it will be based on the time this policy during the policy period. If your actual exposures are was in force, and increased by our short-rate not properly described by those classifications, we will cancelation table and procedure. Final premium assign proper classifications, rates and premium basis will not be less than the minimum premium. by endorsement to this policy. F. Records C. Remuneration You will keep records of information needed to Premium for each work classification is determined by compute premium. You will provide us with copies multiplying a rate times a premium basis. of those records when we ask for them. Remuneration is the most common premium basis. This premium basis includes payroll and all other G. Audit remuneration paid or payable during the policy period You will let us examine and audit all your records for the services of: that relate to this policy. These records include 1. all your officers and employees engaged in work ledgers,journals, registers, vouchers, contracts, tax covered by this policy; and reports, payroll and disbursement records, and programs for storing and retrieving data. We may 2. all other persons engaged in work that could make conduct the audits during regular business hours us liable under Part One(Workers Compensation during the policy period and within three years after Insurance)of this policy. If you do not have payroll the policy period ends. Information developed by records for these persons,the contract price for their audit will be used to determine final premium. services and materials may be used as the premium Insurance rate service organizations have the same basis. This paragraph 2 will not apply if you give us rights we have under this provision. proof that the employers of these persons lawfully secured their workers compensation obligations. 9 of 24 Ed.1-1 5 0Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) PART SIX If you die and we receive notice within thirty days after CONDITIONS your death,we will cover your legal representative as insured. A, Inspection Cancelation We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are 1. You may cancel this policy. You must mail or not safety inspections. They relate only to the deliver advance written notice to us stating when insurability of the workplaces and the premiums to the cancelation is to take effect. be charged. We may give you reports on the 2. We may cancel this policy, We must mail or conditions we find. We may also recommend deliver to you not less than ten days advance changes.While they may help reduce losses, we written notice stating when the cancelation is to do not undertake to perform the duty of any person take effect. Mailing that notice to you at your to provide for the health or safety of your mailing address shown in Item 1 of the Information employees or the public. We do not warrant that Page will be sufficient to prove notice. your workplaces are safe or healthful or that they 3. The policy period will end on the day and hour comply with laws, regulations, codes or standards. stated in the cancelation notice. Insurance rate service organizations have the 4. Any of these provisions that conflict with a law that same rights we have under this provision. controls the cancelation of the insurance in this B. Long Term Policy policy is changed by this statement to comply with the law. If the policy period is longer than one year and E. Sole Representative sixteen days, all provisions of this policy will apply as though a new policy were issued on each The insured first named in Item 1 of the Information annual anniversary that this policy is in force. Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive C. Transfer of Your Rights and Duties notice of cancelation. Your rights or duties under this policy may not be transferred without our written consent. 10 of 24 Ed.1-15 ©Copyright 2013 National Council on Compensation Insurance,Eno All Rights Reserved, it DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 08 (Ed.4-84) PARTNERS, OFFICERS AND OTHERS EXCLUSION ENDORSEMENT The policy does not cover bodily injury to any person described in the Schedule. The premium basis for the policy does not include the remuneration of such persons. You will reimburse us for any payment we must make because of bodily injury to such persons. Schedule Partners Officers Others Nancy Espersen Ann Burton Dave Wilkerson This endorsement changes the policy to which tt Is attached and Is effective on the date Issued unless otherwise stated. (The Information below Is required only when this endorsement Is Issued subsequent to preparation of the policy.) EndorsementElfeclive 02/0812017 Policy No. MWC0106102-01 Endorsement No. Insured: Senior Care of Orange County Inc Premium(See Attached( Insurance Company: Markel Insurance Company Countersigned by WC000308 Ed.4-84 011:1S8-1999 Na dug Consul on CompensalIoo Insurance,Inn. 11 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 04 (Ed.4-84) PENDING RATE CHANGE ENDORSEMENT A rate change filing is being considered by the proper regulatory authority. The filing may result in rates different from the rates shown on the policy. If it does, we will issue an endorsement to show the new rates and their effective date. If only one state is shown in Item IA. of the Information Page, this endorsement applies to that state. If more than one state is shown there, this endorsement applies only in the state shown in the Schedule. Schedule State This endorsement changes the policy to which it is attached and Is effective on the date Issued unless otherwise stated. (The information below Is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 02/08/2017 Policy No. MWC0106102-01 Endorsement No. Insured: Senior Care of Orange County Inc Premium(See Attached) Insurance Company: Markel Insurance Company Countersigned by W0000404 Ed.4-84 W 1983 National Council on Compensation Insurance. 12 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0406 (Ed.8-84) PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies,if any,listed in Item 3 of the Schedule may be eligible for a discount.This endorsement shows your estimated discount in Items 1 or 2 of the Schedule.The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. Schedule 1. State Estimated Eligible Premium First$5,000 Next$95,000 Next$400,000 Balance NC 10.9 12.6 14.4 2. Average percentage discount: % 3, Other policies: 4. If there are no entries in items 1,2 and 3 of the Schedule,see the Premium Discount Endorsement attached to your policy number: This endorsement changes the policy to which it is attached and Is effective on the date issued unless otherwise stated. (The information below Is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 02/08/2017 Policy No. MWC0106102-01 Endorsement No. Insured: Senior Care of Orange County inc Premium(See Attached) Insurance Company: Markel Insurance Company Countersigned by WC000406 (Ed.8-84) e 1983 National Council on Compensation Insurance. 13 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 14 (Ed.7-90) NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 02/08/2017 Policy No. MWC0106102.01 Endorsement No. Insured: Senior Care of Orange County no Premium(See Attached) Insurance Company: Markel insurance Company Countersigned by W0000414 Ed.7-90 outgo National Council on Compensation Insurance. 14 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 (Ed.1-01) PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D.of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM 1D. Premium is amended to read: You will pay all premium when due.You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below Is required only when this endorsement Is issued subsequent to preparation of the policy,) Endorsement Effective 02/08/2017 Policy No, MWC0106102-01 Endorsement No. insured: Senior Care of Orange County Inc Premium(See Attached) Insurance Company: Markel Insurance Company Countersigned by WC000419 Ed.1-01 02000 National Council on Compensation Insurance,Inc. 15 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 D (Ed. 1-15) CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe(other than Certified Acts of Terrorism)as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement(WC 00 04 22 B), attached to this policy. For purposes of this endorsement, the following definitions apply: • Catastrophe(other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident,which results in aggregate workers compensation losses in excess of$50 million. • Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. o Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002(as amended)but that meets all of the following criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. • Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe(other than Certified Acts of Terrorism)is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium NC 0.02 $40.00 This endorsement changes the policy to which It Is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 02/08/2017 Policy No. MWC0106102-01 Endorsement No. Insured Senior Care of Orange County Inc Premium:$(See Attached) Insurance Company Markel Insurance Company Countersigned by WC 00 04 21 A (Ed.1-15) c4 Copyright 2015 National Council on Compensation Insurance,Inc.All Rights Reserved, 16 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 B (Ed. 1-15) TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2015. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act,the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2015. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation)that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1,2015, and ending on December 31, 2020, an amount equal to 20% of our direct earned premiums, during the immediately preceding calendar year. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed$100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds$100,000,000,000; and for aggregate Insured Losses up to$100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceed: a. $100,000,000,with respect to such Insured Losses occurring in calendar year 2015, the United States Government would pay 85%of our Insured Losses that exceed our Insurer Deductible. b. $120,000,000,with respect to such Insured Losses occurring in calendar year 2016, the United States Government would pay 84%of our Insured Losses that exceed our Insurer Deductible. c. $140,000,000,with respect to such Insured Losses occurring in calendar year 2017, the United States Government would pay 83%of our Insured Losses that exceed our Insurer Deductible. d. $160,000,000,with respect to such Insured Losses occurring in calendar year 2018, the United States Government would pay 82% of our Insured Losses that exceed our Insurer Deductible. e. $180,000,000,with respect to such Insured Losses occurring in calendar year 2019, the United States Government would pay 81% of our Insured Losses that exceed our Insurer Deductible. f. $200,000,000,with respect to such Insured Losses occurring in calendar year 2020, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. b Copyright 2015 National Council on Compensation Insurance,Inc.All Rights Reserved. 17 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WC 00 04 22 B WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) 2. Notwithstanding item I above,the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium NC 0.02 $40.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 02/08/2017 Policy No. MWCO106102-01 Endorsement No. Insured Senior Care of Orange County Inc Premium:$(See Attached) Insurance Company Markel Insurance Company Countersigned by WC 00 04 22 B (Ed.1-15) ®Copyright 2015 National Council on Compensation Insurance,Inc.All Rights Reserved. 18 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 24 (Ed. 1-17) AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT Part Five—Premium, Section G. (Audit) of the Workers Compensation and Employers Liability Insurance Policy is revised by adding the following: If you do not allow us to examine and audit all of your records that relate to this policy, and/or do not provide audit information as requested,we may apply an Audit Noncompliance Charge. The method for determining the Audit Noncompliance Charge by state, where applicable, is shown in the Schedule below. If you allow us to examine and audit all of your records after we have applied an Audit Noncompliance Charge, we will revise your premium in accordance with our manuals and Part 5—Premium, E. (Final Premium)of this policy. Failure to cooperate with this policy provision may result in the cancellation of your insurance coverage, as specified under the policy. Note: For coverage under state-approved workers compensation assigned risk plans, failure to cooperate with this policy provision may affect your eligibility for coverage. Schedule State(s) Basis of Audit Noncompliance Maximum Audit Noncompliance Charge Charge Multiplier NC $1,782.00 0.25 This endorsement changes the policy to which it is attached and is effective on the date Issued unless otherwise stated, (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 02/08/2017 Policy No. MWC0106102-01 Endorsement No. Insured: Senior Care of Orange County Inc Premium(See Attached) Insurance Company: Markel insurance Company Countersigned by wC000424 WC 00 04 24 (Ed,1-17) ®Capyslght 2015 NetIonel Council on Compensation Insurance.Inc.AM Rights Reserved. 19 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 32 03 01 C (Ed. 01-14) NORTH CAROLINA AMENDED COVERAGE ENDORSEMENT This endorsement applies only to the insurance provided by the policy because North Carolina is shown in Item 3,A. of the Information Page. The Cancellation Condition of the policy is replaced by this Condition: D. Cancellation And Nonrenewal 1. You may cancel this policy. If you cancel this policy, you must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2, We may cancel this policy. (a) If this policy has been in effect for fewer than 60 days and is not a renewal policy, we may cancel this policy for any reason by giving you at least 30 days prior written notice of cancellation and the reasons for cancellation by registered or certified mail, return receipt requested. (b) If this policy has been in effect for at least 60 days or is a renewal policy,we may not cancel this policy without your prior written consent, except for any one of the following reasons: (1) Nonpayment of premium in accordance with the policy terms. (2) An act or omission by you or your representative that constitutes material misrepresentation or nondisclosure of a material fact in obtaining the policy, continuing the policy, or presenting a claim under the policy. (3) Increased hazard or material change in the risk assumed that could not have been reasonably contemplated by you and us at the time of assumption of the risk. (4) Substantial breach of contractual duties, conditions, or warranties that materially affects the insurability of the risk. (5) A fraudulent act against us by you or your representative that materially affects the insurability of the risk, (6) Willful failure by you or your representative to institute reasonable loss control measures that materially affect the insurability of the risk after written notice by us, (7) Loss of facultative reinsurance or loss of or substantial changes in applicable reinsurance as provided in G.S. 58-41-30. (8) Your conviction of a crime arising our of acts that materially affect the insurability of the risk. (9) A determination by the Commissioner that the continuation of this policy would place us in violation of the laws of North Carolina. (10) You fail to meet the requirements contained in our corporate charter, articles of incorporation, or bylaws, when we are a company organized for the sole purpose of providing members of an organization with insurance coverage in North Carolina. (c) If we cancel for any of the reasons listed in paragraph (b),we must provide you with at least 15 days prior written notice of cancellation stating the precise reason for cancellation. We may provide this notice by registered or certified mail, return receipt requested, to you and any other person designated in the policy to receive notice of cancellation at the addresses shown in the policy or, if not Indicated in the policy, at the last known addresses. Whenever notice of cancellation is given by registered or certified mail, cancellation will not be effective unless and until that method is employed and completed. Notice of cancellation may also be given by any method permitted for service of process pursuant to Rule 4 of the North Carolina Rules of Civil Procedure. Failure to send notice as provided in this paragraph to any other person designated in the policy to receive notice of cancellation invalidates the cancellation only as to that other person's interest, (Ed.41-14) 0 2013 National Council on Compensation Insurance,Inc. 20 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 32 03 01 C (Ed. 01-14) (d) Cancellation for nonpayment of premium is not effective if the amount due is paid before the effective date stated in the notice of cancellation. 3. We may refuse to renew this policy: (a) If this policy is for a term of one year or less, we must provide you with notice of nonrenewal at least 45 days prior to the expiration date of the policy. (b) If this policy is for a term of more than one year or for an indefinite term, then to nonrenew the policy at the policy anniversary date we must provide you with notice of nonrenewal at least 45 days prior to the anniversary date of the policy we must provide you with notice of nonrenewal at least 45 days prior to the anniversary date of the policy, (c) The notice of nonrenewal must state the precise reason for nonrenewal. Failure to send this notice, as provided in paragraphs 3 and 5, to any other person designated in the policy to receive this notice invalidates the nonrenewal only as to that other person's interest. (d) Any nonrenewal attempted or made that is not in compliance with paragraphs(a), (b)and (c) is not effective. Paragraphs(a), (b)and (c)do not apply if you have obtained insurance elsewhere, have accepted replacement coverage, or have requested or agreed to nonrenewal. 4. Whenever we lower coverage limits, raise deductibles, or raise premium rates for reasons within our exclusive control and other than at your request,we will mail you written notice of the change at least 30 days in advance of the effective date of the change. As used in this paragraph, the phrase, "reasons within our exclusive control"does no mean experience modification changes, exposure changes, or loss cost rate changes. 5. We must provide the notice required by paragraphs 3 and 4 by mail to you and any other person designated in the policy to receive this notice at the addresses shown in the policy or, if not indicated in the policy, at the last known addresses. Mailing copies of the notice by regular first-class mail satisfies the notice requirements of paragraphs 3, 4 and 5. 6. We will also send copies of the notice required by this endorsement to the agent or broker of record,though failure to send copies of the notice to the agent or broker of record will not invalidate a cancellation or nonrenewal. Mailing copies of the notice by regular first-class mail to the agent or broker of record satisfies the requirements of this paragraph. Notice of nonrenewal may also be given by any method permitted for service of process pursuant to Rule 4 of the North Carolina Rule of Civil Procedure. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below Is required only when this endorsement Is Issued subsequent to preparation of the policy.) Endorsement Effective 02/08/2017 Policy No. MWCO106102-01 Endorsement No. Insured: Senior Care of Orange Premium (See Attached) County Inc Insurance Company: Markel Insurance Company Countersigned by (Ed.01-14) 02013 National Council on Compensation Insurance,Inc. 21 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED WC 32 03 01 0 (Ed,01.14) ®2013 National Council on Compensation Insurance,ino. 22 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED A STOCK COMPANY MARKEL) Markel Insurance Company Ten Parkway North Deerfield, Illinois 60015 Servicing Office Mailing Address: Markel Service, Inc. Central Park Plaza 222 South 15th Street, Suite 1500N Omaha, NE 68102-1656 (888)500-3344 YOUR INSURANCE POLICY Coverage afforded by this policy is provided by the Company(Insurer)and named in the Declarations. In Witness Whereof, the company has caused this policy to be executed and attested and countersigned by a duly authorized representative of the company identified in the Declarations. 0 I Richard R. Grinnan, Secretary Francis Crowley, President MJWC 1000 08 12 23 of 24 DocuSign Envelope ID:30CFBA21-DC65-423A-A674-7D24A692C6ED INTERLINE MARKEL' PRIVACY NOTICE We are committed to safeguarding your privacy.We understand your concerns regarding the privacy of your nonpublic personal information. No nonpublic personal information is required to be collected when you visit our websites; however, this information may be requested in order to provide the products and services described,We do not sell nonpublic per- sonal information to non-affiliated third parties for marketing or other purposes.We only use and share this type of infor- mation with non-affiliated third parties for the purposes of underwriting insurance,administering your policy or claim and other purposes as permitted by law,such as disclosures to insurance regulatory authorities or in response to legal pro- cess. Notwithstanding the foregoing,we may use this information for the purpose of marketing our own products and ser- vices to you, We collect nonpublic personal information about you from the following sources: • Information we receive from you on applications or other forms; • Information about your transactions with us,our affiliates,or others;and/or • Information we receive from consumer reporting agencies and inspection reports. We do not disclose any nonpublic personal information about our customers/claimants or former customers/claimants to anyone,except as permitted by law. We may disclose nonpublic personal information about you to the following types of third parties: • Service providers,such as Insurance agents and!or brokers and claims adjusters;and/or • Other non-affiliated third parties as permitted by law. We restrict access to nonpublic personal information about our customers/claimants to those individuals who need to know that information to provide products and services to our customers/claimants or as permitted by law,We maintain physical,electronic,and procedural safeguards to guard your nonpublic personal information. Residents of California: You may request to review and make corrections to recorded non-public personal information contained in our files.A more detailed description of your rights and practices regarding such information Is available upon request. Please con- tact your agent/broker for instructions on how to submit a request to us. MPIL 1007 03 14 Page 1 of 1 24 of 24