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HomeMy WebLinkAbout2018-205-E Health - Elavon credit card feesDocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 N E W C O M P A N Y A P P L I C A T I O N- G O V E R N M E N T/ I N S T I T U T I O N A L USA- GOV -ELV -0218 COMPANY INFORMATION 0 ♦ DBA NAME: Orange County Government CONTACT NAME: Gary Donaldson ♦ DBA ADDRESS TYPE: Business ♦ DBA ADDRESSI (NO PO BOX): 200 S. Cameron Street DBA ADDRESS 2: ♦ CITY: Hillsborough ♦ STATE NC ♦ ZIP CODE: 27278 ♦ COUNTRY OF PRIMARY BUSINESS OPERATIONS: USA ♦ BUSINESS COUNTRY OF FORMATION: USA ♦ DBA PHONE #: (919)245 -2453 ► DOES COMPANY HAVE THE ABILITY TO ISSUE BEARER SHARES AS OWNERSHIP STAKE IN THE COMPANY? No (REQUIRED IF COUNTRY OF FORMATION IS OUTSIDE OF THE U.S. AND BUSINESS STRUCTURE EQUALS C CORPORATION - CLOSELY HELD, PRIVATE COMPANY, PROF CORP, PUBLIC COMPANY, SUB S CORP, LIMITED LIABILITY COMPANY) DBA FAX #: YEAR ESTABLISHED: MOBILE PHONE #: ♦ LENGTH OF CURRENT OWNERSHIP: YEARS, MONTHS ♦ EMAIL ADDRESS: gdonaldSon@orangecountync.gov CIP EXEMPTION: BENEFICIAL OWNER EXEMPTION: OTHER ADDRESS IFDIFFERENTTHANABOVE ® MAILING ❑ SHIPPING ❑ SEE ALSO SPECIAL INSTRUCTIONS (MORE THAN ONE OPTION MAY BE SELECTED) In - LOCATION NAME: Orange County Health Department PHONE #: (919)245 -2414 CONTACT: Rebecca Crawford FAX #: (919)644 -3007 ADDRESS: 300 W. Tryon Street CITY: Hillsborough STATE: NC ZIP CODE: 27278 STATEMENTS/ RETRIEVALS /CHARGEBACKS STATEMENTS: ❑ DBA OR ® MAILING OR ❑ W -9 AUTO SEND: ® YES ❑ No (CHAIN COMPANIES ONLY- MUST INCLUDE CHAIN SETUP FORM) RETRIEVALS: MAIL TO: ❑ DBA ® MAILING OR FAX TO: ❑ DBA ❑ MAILING OR EMAIL TO: OR ❑ ONLINE CASE MANAGEMENT (OCM) CHARGEBACKS: MAIL TO: ❑ DBA O MAILING AND FAx To: ❑ DBA ❑ MAILING OR EMAIL TO: OR ❑ ONLINE CASE MANAGEMENT (OCM) 0 CONTACT INFORMATION AUTHORIZED REP ♦ ❑ OFFICER ❑ MANAGER ® AUTHORIZED REPRESENTATIVE ❑ OTHER: ♦ FIRST NAME: Rebecca MN: ♦ LAST NAME: Crawford ♦ TITLE: Finance and Admin Services Director ♦ US PERSON: Yes ►CONTACT ADDRESS (No PO BOX): 300 W. Tryon Street ►ADDRESSTYPE: Business ►CITY: Hillsborough ►STATE: NC ►ZIP CODE: 27278 ►DOB: 05 -23 -81 CONTACT PHONE M 9192452414 INDIVIDUAL ID EXEMPTION CLASS: GOVERNMENT ❑ FEDERAL ❑ STATE ❑ LOCAL (POLITICAL SUBDIVISION OF A US STATE) OTHER COMPANY INFORMATION ♦ AVERAGE SALE AMOUNT: $ 171 ♦ CARD PRESENT 98% ♦ CARD NOT PRESENT* 2% ♦ INTERNET* 0% (MUST TOTAL 100 %) ►INTERNET : PRODUCT WEBSITE: l� + +n• / /..n.n.. i.r�nnsni...n +.inn ..i... /i+en.�.+.nen +c /L�e- �I+t�/ ►INTERNET: "CONTACT US" EMAIL: *CUSTOMER SERVICE PHONE # AND PREVIOUS PROCESSOR REQUIRED BELOW ►CUSTOMER SERVICE PHONE #: (919)245-2414 ►PREVIOUS PROCESSOR: First Data ♦ HIGH SALE AMOUNT: $ 861 ♦ NUMBER OF HIGH SALES (ABOVE) ANNUALLY:1 ♦ TOTAL MONTHLY VISA/MC /AMEX/DISC /UNIONPAY SALES: $ 3,000 ♦ ANNUAL REVENUE: $ 39,000 ♦ DESCRIPTION OF PRODUCT /SERVICES OFFERED: Medical Clinic Services SPECIAL PROGRAM MCC ONLY: WHEN DOES THE CUSTOMER RECEIVE THE PRODUCT OR SERVICE? IF NOT SAME DAY, # OF DAYS (INCLUDE SHIPPING TIME FRAME) IF SEASONAL, PLEASE CHECK MONTHS CLOSED BELOW. (CUSTOMER MUST CONTACT CUSTOMER SERVICE TO DEACTIVATE AND REACTIVATE ACCOUNT) ❑ JANUARY ❑ FEBRUARY ❑ MARCH ❑ APRIL ❑ MAY ❑ ,JUNE ❑ JULY ❑ AUGUST ❑ SEPTEMBER ❑ OCTOBER ❑ NOVEMBER ❑ DECEMBER BANK ACCOUNT (CHECKING ACCOUNTS ONLY) ♦ DEPOSIT BANK NAME: Su nTrust ♦ ABA/ROUTING #: 061000104 ♦ DDA ACCOUNT #: 401036167 BILLING /CHARGEBACK BANK NAME (IF DIFFERENT): ABA/ROUTING #: DDA ACCOUNT #: CHARGEBACK BANK NAME (IF DIFFERENT THAN BILLING): ABA/ROUTING #: DDA ACCOUNT #: @@ El FAST FAST TRACK FUNDING MONTHLY FEE USA- GOV -ELV -0218 DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 CARD ACCEPTANCE (PLEASE CHECK EACH CARD YOU WISH TO ACCEPT.) PRICING CATEGORY ❑ ALL VISA /MASTERCARD /AMEX/UNIONPAY/ q�py� `/'� /� Y /{ ® RETAIL ❑ SUPERMARKET DISCOVER CARDS (JCB, DI, PAY PAL PAYMENT DEVICE) El RESTAURANT ❑ MO /TO /INTERNET ® VISA CREDIT ® VISA DEBITED MC CREDIT ® MC DEBIT ® DISCOVER(JCB, DI, PAY PAL PAYMENT DEVICE) ❑ UNIONPAY ❑ AMEX ❑ LODGING ❑ ARU PRICING INFORMATION FEES VISA/MASTERCARD /U N ION PAY/ PRICING PROGRAM: DISCOVER CARDS AMERICAN EXPRESS APPLICATION $0 JCB DI PAY PAL PAY DEVICE (FIXED ONLY) RATE' PER ITEM' RATE PER ITEM INSTALLATION/TRAINING $0 QUALIFIED % $ % $ REPORTING & SUPPORT PACKAGE (PER MONTH) $0 MID QUALIFIED % $ % $ MONTHLY MINIMUM $15 NON QUALIFIED % $ % $ CHARGEBACK(PER OCCURRENCE) $15 0 wOPT. ❑ CHECK CARD ❑ SPRMKT ❑ QPS /SMALL TKT RETURN ITEM /NSF (PER OCCURRENCE) $20 ~ % $ STATEMENT: ® ELECTRONIC OR ❑ PAPER MONTHLY STATEMENT MAILING PAPER STATEMENTS ONLY $10 OPT. REWARDS 0 00% $ OPT. COMMERCIAL CARD % $ RUSH SHIPMENT $ INTERCHANGE PLUS .015 % $ % $10 VERIZON DATA PLAN (PER DEVICE): (PER MONTH) $ CHECK CARD QUALIFIED % $ VERIZON DATA PLAN OVERAGE (PER MB) $ 0,05 QUALIFIED % $ % $ OTHER: $ CL U REWARDS QUALIFIED % $ AUTHORIZATIONS vMID QUALIFIED % $ % $ VISA (PERAUTH) $ VOICE -ARU (PER AUTH) $0.85 = COMMERCIAL NON QUALIFIED % $ MASTERCARD (PERAUTH) $ VOICE OPERATOR (PERAUTH) $0.85 z W NON QUALIFIED % $ % $ DISCOVER(PERAUTH) $ VOICE - AVS(PERAUTH) $0.85 FIXED - PRICING PGM: % $ % $ UNIONPAY (PERAUTH) $ VOICE BANK REF (PERAUTH) $0.85 *RATESAREFORALL CARDACCEPTANCE TYPES SELECTED. ALL CARD BRAND ASSESSMENTS WILL REPASSED THROUGHATCOST. PCI SECURITY PROGRAM /SAFE -T PACKAGE AMEX (PERAUTH) $ DIAL COMMUNICATION (PERAUTH) $0.024 SECURITY PROGRAM (PER MONTH): /PCI $! / PIN DEBIT (ALL DEBIT NETWORK FEES WILL BE PASSED THROUGH AT COST) SOLUTION PACKAGE PIN DEBIT MONTHLY FEE $ $ IC PLUS (PERAUTH) $ IC PLUSIENH. IC PLUS: MONT =ICPLS /AUTH= ASSOC),(TIERED /DIFFERENTIAL: MONT =ICDIF /AUTH= ASSOC) (PER MONTH. PLUS TAXES, IF APPLICABLE) OTHER CARD TYPES EXISTING AMEX SE # (10 DIGITS): PER AUTH: $ EBT SE # (7 DIGITS): PER AUTH: $ USA- GOV -ELV -0218 DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 POINT OF SALE EQUIPMENT OR SOFTWARE NETWORK: ® ELAVON [I OTHER # OF TIDS: ❑ A THIRD PARTY INTEGRATOR WILL BE USED FOR IMPLEMENTATION: VAR SERVICE PROVIDER (HOSTED): VAR (DISTRIBUTED): VENDOR: PRODUCT: VERSION: PURCHASE /SETUP LEASE ** SOFTWAREIWIRELESS QTY POS DESCRIPTION ITEM CODE TERMINAL OWNS REPROG FEE PRICE TERM MONTHLY RATE ANNUALFEE MONTHLY FEE PER AUTH ENCRYPT PER UNIT PER UNIT MONTHLY PER UNIT PER UNIT UNIT FEE @ @ @ @PER ❑ ❑ $ $ $ $ W $ ❑ ❑ $ $ $ $ $ ❑ ❑ $� $ $ $ W Q @$ ❑ ❑ "'PLEASE NOTE THAT ALL LEASES MUST COMPLETE THE SECTION IMMEDIATELY BELOW. INITIALS ARE REQUIRED. ALL APPLICABLE STATE AND LOCAL TAXES WILL BE APPLIED. El SALES TAX EXEMPT Elavon and Member have no responsibility for, and shall have no liability to Company in connection with, any hardware or software, or any related services, Company receives under a direct agreement (including any sale, warranty or end -user license agreement) between Company and a third party, including any Value Added Sewicer, even if Elavon collects fees or other amounts from Company with respect to such hardware, software or services. DESCRIPTION SETUP FEE ANNUAL FEE MONTHLY FEE PER AUTH FEE [ADDITIONAL POS SERVICES: � @ $ @ $ $ TERMINAL PROGRAMING INSTRUCTIONS DO NOT USE FOR CONVERGE —THIS INFORMATION IS COVERED DURING TRAINING ❑ RETAIL AUTO CLOSE DEFAULT QUICK CLOSE El STORE AND FORWARD El NO SIGNATURE ❑ CONTACTLESS + NO SIGNATURE ❑ RESTAURANT (QUICK CLOSE DEFAULT) TIP FUNCTION (DEFAULT) ❑ FINE DINING ❑ TAB FUNCTION ❑ CARD NOT PRESENT (AUTO CLOSE DEFAULT) ❑ QUICK CLOSE ❑ LODGING (QUICK CLOSE DEFAULT) ❑ QUICK STAY CUSTOM PROMPTS: El TERMINAL AUTO CLOSE (RTL, MOTO) TIME ZONE El CASH BACK PIN DEBIT (RTL): $ (MAx) ❑CUSTOM FOOTER: ❑ NO TIP (REST) ❑ NO SERVER PROMPT (REST) ❑ CLERK PROMPT (RTL) ❑ TIP FUNCTION WAITER (RTL) ❑ TIP FUNCTION CASHIER (RTL) COMMUNICATION METHOD (IP DEFAULT): ❑ DIAL TRAINING (DEFAULT = TRAINING REQUIRED): ❑ NO TRAINING I PHONE INFORMATION: ACCESS #: X I understand that I am entering into a -month commercial equipment lease for credit -card processing equipment. I understand this is a NOW CANCELLABLE commercial equipment lease and that I will be required to make monthly payments of $ under this lease for the entire -month term, regardless of any representations made by the Sales Representative. Under a -month term with a monthly payments of $ , I understand the approximate total cost equipment lease to be $ . I also realize that I will have to pay applicable sales tax every month and, if I do not provide evidence of insurance, I will be charged an l nal $4.95monthly to cover equipment. I understand the equipment lease may be more expensive than purchasing the same equipment outright, and that I have had an nity to research the cost to purchase the same equipment outright. As an alternative to a lease, I understand I may purchase the equipment outright at the time of the lease appcation for the amount of $ Finally, I understand that I will be personally responsible for making payments under this lease and that any failure to pay all amounts when due may result in additional charges, potential damage to my credit rating, and /or legal action against me to collect both past and future payments owed under the lease. The end of lease residual value is $ plus taxes if applicable. Company hereby authorizes Elavon, through its Ladco Leasing division ( "Lessor'), to automatically withdraw Company's monthly lease payments and any amounts, including any and all taxes or other charges, owed in accordance with the lease, as applicable, by initiating debit entries to Company's account at the financial institution ("Bank ") indicated hereon or such other financial institution used by Company from time to time. A lease payment (whether paid by debit or other means) that is not honored by Bank for any reason will be subject to a returned item service fee imposed by Lessor. Upon completion of the lease term, this authorization shall remain in effect until Lessor has received written notice from Company of its termination. I, BANK NAME: I ABA/ROUTING #: IDDA ACCOUNT #: ELECTRONIC CHECK SERVICE ►ANNUAL CHECK VOLUME: $ ►AVERAGE CHECKAMOUNT: $ /MAXIMUM CHECK AMOUNT: $ /ECS MONTHLY MINIMUM: $ ECS — PAPER CHECK CONVERSION PROCESSING OPTIONS: ❑ CONVERSION WITH GUARANTEE GUARANTEE RATE: % PER TRANSACTION: $ ❑ POP (POS IMAGE) @ ❑ CONVERSION W/ VERIFICATION OR PER TRANSACTION: $ PER RETURN TRANSACTION: $ ❑ El ARC (POS IMAGE) ❑ BOC ❑ CONVERSION ONLY COLLECTIONS ACH CHECK —CHECK NOT PRESENT (CNP) PROCESSING OPTIONS: ❑ CONCURRENT ENROLLMENT (INCLUDES: WEB, TEL, PPD AND CCD) = XNP @ PER TRANSACTION:.PO INDIVIDUAL ENROLLMENT - CHOOSE ONE (ONE PER MID) ❑ ACH - ECHECK W ITH VERIFICATION ❑ WEB —INTERNET INITIATED ❑ PPD — PREARRANGED PAYMENT PER RETURN TRANSACTION: p TION: El TEL /IVR — TELEPHONE INITIATED El CCD — CORPORATE TO CORPORATE PER TRANSACTION: $ ❑ ACH — ECHECK CONVERSION ONLY CONVERGE SETUPS WILL BE CONCURRENTL Y ENROLLED INALL PRODUCT TYPES =XNP @ PER RETURN TRANSACTION: $ OTHER ECS CHECK CONVERSION SERVICE REQUESTS ❑ PROMPTS FOR DRIVER'S LICENSE (IF NOT ❑ NSF SERVICE FEE PROCESSING @ $2 PER NSF ITEM. NOT APPLICABLE FOR GUARANTEE S ERVICE SELECTED, INFORMATION MUST BE OBTAINED C1 @@ NSF SERVICE FEE AMOUNT: MAX ALLOWED OR ❑ SPECIFIED SERVICE FEE AMOUNT .p (STATE MAX IS DEFAULT) ON CHECK FOR GUARANTEE SERVICE) @ ACH ECHECK NSF SERVICE FEE AMOUNT: El .P1 S (DEFAULT) OR ❑ SPECIFIED SERVICE FEE AMOUNT SPECIFY NSF RESUBMISSION ATTEMPTS: ❑ 0 OR ❑ 1 (2 IS THE DEFAULT) ❑ ENQUIRE REPORTING ACCESS: # OF USERS: @ $29.95 EACH PER ACH — ECHECK QUESTIONNAIRE 1. WHAT TYPES OF PAYMENTS WILL YOU ACCEPT USING ACH - ECHECK (E.G., UTILITY BILL PAYMENTS, MONTHLY RENT PAYMENTS, MONTHLY BILLING FOR GENERAL SERVICES)? 2. WILL YOU OBTAIN AUTHORIZATION FROM YOUR CUSTOMERS PRIOR TO ACCEPTING AN ACH ENTRY IN ACCORDANCE WITH THE ECS OPERATING GUIDE (E.G., ORALLY VIA TELEPHONE FOR TEL/IVR, OR IN WRITING FOR PPD)? ❑ YES ❑ No 3. WILL YOU VERIFY AND AUTHENTICATE THE IDENTITY OF YOUR CUSTOMERS IN ACCORDANCE WITH THE ECS OPERATING GUIDE PRIOR TO INITIATING ACH ENTRIES FOR THOSE CUSTOMERS (E.G., BY OBTAINING A CUSTOMER'S NAME, ADDRESS AND TELEPHONE NUMBER OR USING A DATABASE TO VERIFY THE ACCURACY OF THE INFORMATION PROVIDED BY CUSTOMER)? ❑ YES []No 4. W ILL YOU OFFER ACH - ECHECK TO EXISTING OR NEW CUSTOMERS? ❑ EXISTING ❑ NEW 5. WILL YOU MAINTAIN AND DISCLOSE TO YOUR CUSTOMERS PROCEDURES FOR CANCELLING AN AUTHORIZATION? ❑ YES ❑ No 6. WILL YOU ENSURE THAT INFORMATION REGARDING EACH TRANSACTION AUTHORIZATION ENTERED BY A CUSTOMER AND /OR YOUR SERVICE REPRESENTATIVE IS ACCURATE AND NOT A DUPLICATE TRANSACTION? ❑ YES ❑ No USA- GOV -ELV -0218 DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 REPORTING TOOLS CONVENIENCE FEE SERVICES PROGRAMS ® MCP ONLY OR ❑ MCP WITH OCM ► MONTHLY FEE $ 0SETUP FEE $ /# USERS /SET UP TYPE (CHECK ONE) [I MID C1 CHN ❑ ACS ►MONTHLY FEE $ /SET UP FEE $ /REMOTE ID OTHER VAS CONVENIENCE FEE FUNDING MODEL (CHECK ONE): FO Dynamic Currency Conversion (DCC): ❑ COMPANY MANAGED CONVENIENCE FEE' DCC Conversion Rate: % DCC Rebate: % Annual DCC Registration Fee: $ DCC Exchange Rate Source: US Bank CONVENIENCE FEE AND GOVERNMENT /PUBLIC INSTITUTION SERVICE FEES (GPISF) CONVENIENCE FEE SERVICES PROGRAMS GPISF SERVICES PROGRAMS CHECK ALL THAT APPLY, BUT ONLY IF COMPANY ELECTS GPISF ASSESSMENTS: ❑ COMPANY - MANAGED SERVICE FEE' CONVENIENCE FEE FUNDING MODEL (CHECK ONE): ❑ COMPANY- MANAGED WITH ELAVON POS DEVICES /SERVICE FEE TERMINALS4 ❑ COMPANY MANAGED CONVENIENCE FEE' ❑ ELAVON- MANAGED SERVICE FEES ❑ ELAVON MANAGED CONVENIENCE FEE' CARD ACCEPTANCE (CHECK ALL THAT APPLY): PAYMENT TRANSACTION TYPES ❑ POINT OF SALE ❑ INTERNET ❑ CREDIT (CHECK ALL THAT APPLY): ❑ IVR ❑ OTHER: ❑ VISA ❑ MASTERCARD ❑ DISCOVER GPISF SERVICES PROGRAMS (CHECK ALL THAT APPLY, BUT ONLY IF COMPANY ELECTS GPISF ASSESSMENTS: ❑ SIGNATURE DEBIT (CHECK ALL THAT APPLY): ❑ MASTERCARD GOVERNMENT AND EDUCATION PAYMENT PROGRAM ❑ VISA ❑ MASTERCARD ❑ DISCOVER ❑ PIN -BASED DEBIT ❑ ACH (VIA ELECTRONIC CHECK SERVICES) ELAVON PRODUCT SUPPORTING ELAVON- MANAGED CONVENIENCE FEE ASSESSMENT TO BE USED BY COMPANY (CHECK ALL THAT APPLY): ❑ COMPANY PROPRIETARY SOLUTION OR SERVICE PROVIDER ❑ OTHER: CONVENIENCE FEE PRICING: CONVENIENCE FLAT FEE AMOUNT: CONVENIENCE FEE %: (MASTERCARD, DISCOVER & ACH PROGRAMS ONLY) IMPLEMENTATION FEE (IF APPLICABLE): ❑ VISA GOVERNMENT AND EDUCATION PAYMENT PROGRAM TRANSACTION TYPES: ❑ FEDERAL INCOME TAX ❑ GOVERNMENT FEES ❑ STATE INCOME TAX ❑ REAL ESTATE PROPERTY TAX ❑ BUSINESS TAX ❑ OTHER TAX ❑ TUITION ❑ OTHER EDUCATION EXPENSES PAYMENT TYPES FOR GPISF ASSESSMENT (NOT ALL PAYMENT TYPES ARE SUPPORTED FOR ALL PROGRAMS)(CHECK ALL THAT APPLY. BUT ONLY IF COMPANY ELECTS GPISF ASSESSMENT): ❑ CREDIT — (CHECK ALL THAT APPLY): ❑ VISA — ELIGIBLE MCCS: 8211, 8220, 8244, 8249, 9211, 9222, 9311, 9399 ❑ MASTERCARD - ELIGIBLE MCCS: 8211, 8220, 8299, 9211, 9222, 9223, 9311, 9399, 9402 ❑ DISCOVER (AVAILABLE IF ELAVON- ACQUIRED) ❑ SIGNATURE DEBIT - (CHECK ALL THAT APPLY) ❑ VISA— ELIGIBLE MCCS: 8211, 8220, 8244, 8249, 9211, 9222, 9311, 9399 ❑ MASTERCARD — ELIGIBLE MCCS: 8211, 8220, 8299, 9211, 9222, 9223, 9311, 9399, 9402 ❑ DISCOVER (AVAILABLE IF ELAVON- ACQUIRED) ❑ ACH (VIA ELECTRONIC CHECK SERVICES) ELAVON PRODUCT SUPPORTING GPISF ASSESSMENT TO BE USED BY COMPANY (CHECK ALL THAT APPLY): ❑ SERVICE FEE TERMINAL ❑ COMPANY PROPRIETARY SOLUTION OR SERVICE PROVIDER ❑ SAFE -T SERVICES (ADDITIONAL ENROLLMENTFORM REQUIRED) ❑ OTHER: GPISF PRICING: CREDIT CARD SERVICE FEE: % OR $ SIGNATURE DEBIT SERVICE FEE: % OR $ ACH (VIA ELECTRONIC CHECK SERVICES): $ IMPLEMENTATION FEE (IF APPLICABLE): $ I "Company- Managed" Convenience Fee means that Company establishes the amount of the Convenience Fee (subject to the requirements of the Agreement and applicable Payment Network Regulations) and retains the Convenience Fee. Company pays Elavon the per transaction fees as set forth in this application to the Agreement for all Convenience Fee Transactions. 2 "Elavon- Managed" Convenience Fee means that Elavon establishes the amount of the Convenience Fee and retains the Convenience Fee in lieu of Company's obligation to pay Elavon the per transaction fees as set forth in this application to the Agreement for Convenience Fee Transactions. The Convenience Fee is still charged by Company and included in the overall transaction amount charged to the Cardholder. I "Company- Managed" Service Fee means that Company establishes the amount of the GPISF, programs its POS Devices to assess the GPISF, and retains the GPISF (subject to the requirements of the Agreement and applicable Payment Network Regulations). Company pays Elavon the per transaction fees as set forth in this application for all GPISF Transactions. 4 "Company- Managed with Elavon POS Devices /Service Fee Terminals" means that Elavon programs the POS Devices to assess the GPISF established by Company and Company retains the GPISF. Company pays Elavon the per transaction fees as set forth in this application to the Agreement for all GPISF Transactions. I "Elavon- Managed" Service Fee means that Elavon establishes the amount of the GPISF, and Elavon charges and retains the GPISF in lieu of Company's obligation to pay Elavon the per transaction fees and Safe -T Services fees (if Safe -T is chosen above) for GPISF Transactions. 4 USA- GOV -ELV -021 E DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 SUBSTITUTE FORM W -9 ® GOVERNMENT ❑ NON- PROFIT CHARITABLE OR SOCIAL (INCLUDE DOCUMENTS THAT SUPPORT TAX EXEMPT STATUS) ❑ OTHER ♦ LEGAL BUSINESS NAME*: Orange County Government `NAME OF BUSINESS AS SHOWN ON YOUR BUSINESS INCOME TAX RETURNS. FOR SOLE PROPRIETORS, THIS SHOULD ALWAYS BE THE OWNER'S NAME. ♦ LEGAL BUSINESS ADDRESS (NO PO BOX): ZOO S. Cameron Street /TIN (EMPLOYER ID #): 556-6000327 • CITY: Hillsborough ♦ STATE: NC ♦ ZIP CODE: 27278 OR /TIN (SOCIAL SECURITY #): REPRESENTATIONS AND CERTIFICATIONS ®COMPANY Company Representations and Certifications. By signing below, the applicant company ( "Company") and its representatives) represent and warrant to Elavon, Inc. ( "Elavon" or "member" as applicable), with offices at 7300 Chapman Highway, Knoxville, TN 37920 (collectively, "we" or "us ") that (i) all information provided in this company application ( "Company Application ") is true and complete and properly reflects the business and financial condition of Company; and (ii) the persons signing this Company Application are duly authorized to bind Company to all provisions of this Company Application and the Agreement. The signature by an authorized representative of Company on the Company Application, or the transmission of a Transaction Receipt or other evidence of a Transaction to us, shall be the Company's acceptance of and agreement to the terms and conditions contained in the Agreement including, without limitation, this Company Application, the Terms of Service ( "TOS "), the Addendum to the Terms of Service for Government/Institutional Companies attached hereto, and the Operating Guide incorporated herein by this reference and located at our website at https:// www. merchantconnect .conVCWRWeb /i)df/TOS ENG.pdf and htti)s:// www .merchantconnect.com/CWRWeb /odf /OPERATING GUIDE Eng.pdf, respectively. If you are accepting electronic payments through Transend Pay you also agree to the Terms and Conditions set out under the Resources tab at www.elavon.com/transendpay, and as subsequently amended in the Operating Guide in the Transend Pay Services Chapter. If Company does not have access to view the TOS or Operating Guide at our website please contact our customer service center. Notwithstanding any such non - receipt of the TOS or Operating Guide, Company agrees to comply with the Agreement, and all applicable laws, rules, and regulations including the rules and regulations of the Payment Networks, and understands that failure to comply will result in termination of processing services. Capitalized terms shall, unless otherwise defined in this Company Application, have the same meaning ascribed to them in the TOS and Operating Guide. Company must obtain an Authorization Code via electronic terminal or similar device before completing any transaction. Company understands that an AUTHORIZATION CODE IS NOT A GUARANTEE OF ACCEPTANCE OR PAYMENT OF A TRANSACTION. RECEIPT OF AN AUTHORIZATION CODE DOES NOT MEAN THAT COMPANY WILL NOT RECEIVE A CHARGEBACK FOR THAT TRANSACTION. Company and its representative(s) authorize us prior to our acceptance of this Company Application and from time to time thereafter, to investigate the business history and background of Company and to obtain credit reports or other background investigation reports on Company that we consider necessary to review the acceptance and continuation of this Company Application. Company also authorizes any person or credit reporting agency to compile information to answer those credit inquiries and to furnish that information to us. IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT. To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. This means we will ask for certain information and identifying documents to allow us to identify you. This Company Application may be signed in one or more counterparts, each of which shall constitute an original and all of which, taken together, shall constitute one and the same Company Application. Delivery of executed counterparts of this Company Application may be accomplished by a facsimile transmission, and a signed facsimile or copy of this Company Application shall constitute a signed original. All companies must comply with the requirements of the Payment Card Industry Data Security Standards ( "PCI DSS "). Elavon requires Level 4 companies (determined based on Transaction volume) to validate PCI DSS compliance on an annual basis, with initial validation to occur no later than ninety (90) days after account approval. Any company that has not validated PCI DSS compliance within ninety (90) days of account approval, or in subsequent years on or before the anniversary date of account approval, will be charged a monthly non - compliance fee of $59.99 until Elavon is provided with validation of PCI DSS compliance. Company may be eligible for Data Breach Financial Assistance Coverage following account approval and PCI DSS compliance validation. See the PCI Compliance Program Overview for assistance details and conditions. American Express Acceptance Program (Acceptance Program). If Company has elected to accept American Express® Transactions (as indicated in the Card Acceptance section of this Company Application), in addition to all other terms of this Agreement, Company agrees to the Acceptance Program terms of the TOS. By signing below or by accepting a Transaction initiated with an American Express® Payment Device, Company expressly authorizes Elavon to submit American Express® Transactions to, and to receive settlement funds from, American Express on Company's behalf. Company further authorizes Elavon to provide Company's contact information to American Express, and Company agrees that American Express may use and share such contact information for its business purposes and as permitted by applicable Laws, including to communicate with Company regarding products, services, and resources available to Company's business. American Express's use of the email address and mobile phone number provided above is subject to the consent to such use as indicated in Section 1 of this Company Application. Consent to American Express's use of contact information for such communications may be withdrawn at any time by contacting our customer service center. Even if consent is withdrawn, Company may still receive messages related to important information about Company's account from American Express. Company or Elavon may terminate Company's acceptance of American Express® Payment Devices at any time, with or without cause, without affecting Company's rights and obligations pursuant to the remainder of this Agreement. Company acknowledges that, if at any time Company is no longer qualified to participate in the Acceptance Program, Company may be enrolled in the standard American Express® card acceptance program, which may have different terms and conditions than the Acceptance Program, and Company's acceptance of American Express® Payment Devices pursuant to this Agreement will be terminated. Company acknowledges that American Express is an intended third -party beneficiary of this Agreement, solely with respect to the terms and conditions applicable to Company's acceptance of Am Devices, and that American Express has the right to enforce such terms and conditions directly against Company. ♦ SIGNATURE: X dl/:'I/LIL N , ♦ PRINTED NAME: Bonnie Hammersley ♦ TITLE: County Manager ♦ DATE:6/15/2018 5 SIGNATURE: X PRINTED NAME: TITLE: DATE: • • To the best of my knowledge, I certify that the information provided in this Company Application was provided by the Company and is true, complete and accurate. I further certify that the signatures were provided by the Company's authorized representative. ♦ PRINTED NAME: ♦ REP ID #: ♦ DATE: ♦ REP PHONE #: ♦ REP EMAIL: USA -GOV -ELV -0218 USA -GOV -ELV -0218 DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 ADDENDUM TO THE TERMS OF SERVICE FOR GOVERNMENTANSTITUTIONAL COMPANIES The following provisions hereby replace the like - numbered provisions of the Terms of Service ( "TOS ") or are hereby inserted or deleted from the TOS, as indicated, for Companies operating under the Agreement. 1) Section 10.1Audit is revised to read as follows: "Audit. If Elavon or Member reasonably suspects that they are subject to a financial or reputational risk due to Company's actions or omissions, Company authorizes Elavon and its agents to perform an audit or inspection of Company's operations and records to confirm Company's compliance with the Agreement upon reasonable advance notice, during normal business hours, and at Elavon's expense (unless Elavon reasonably determines based on such audit that Company is not in compliance with the Agreement, in which case Company will bear the cost). Company will obtain and submit a copy of an audit from a third party acceptable to Elavon of the financial, physical security, information security, and operational facets of Company's business at its expense when requested by Elavon. Further, Company acknowledges and agrees that the Payment Networks have the right to audit Company's business to confirm compliance with the Payment Network Regulations. Company will maintain complete and accurate records of its performance under the Agreement. Company will execute and deliver to Elavon all documents Elavon reasonably deems necessary to verify Company's compliance with Section 8.1." 2) Section 13 Indemnification is deleted and replaced with the following two sections: "13(a). Company Responsibilities. As between Company, Elavon and Member, Company will be responsible for, and at its own expense, defend itself against any suits, claims, losses, demands or damages arising out of or in connection with (A) any dispute with a Customer, Cardholder or any third party relating to any Transaction, (B) any action taken by Elavon or Member with respect to the DDA or Reserve Account in accordance with the Agreement, or (C) any breach by Company of any obligation under this Agreement. Company will not make any claims against Elavon or Member for any liabilities, claims losses, costs, expenses and demands of any kind or nature, arising out of or in connection with any of the foregoing suits, claims, losses, demands or damages. 13(b). Elavon Responsibilities. Elavon will be responsible for and will at its own expense defend itself against any suits, claims, losses, demands or damages arising out of (A) Elavon's breach of the Agreement, or (B) Elavon's negligence, gross negligence or willful misconduct." 3) Section 16 Personal Guaranty is deleted. 4) Section 18.2 Governing Law in the United States is deleted. 5) Section 18.3 Exclusivity is deleted. 6) Section 18.5 Assignability is revised as follows: "Assignability. Company will not assign the Agreement, directly, by operation of law, or by change of control of Company, without Elavon's prior written consent. If Company nevertheless assigns the Agreement without Elavon's consent, the Agreement will be binding on both the assignee and Company. Elavon will not transfer or assign the Agreement without the prior written consent of Company, provided that such consent will not be required for (i) the assignment or delegation to an affiliate of Elavon, or (ii) the assignment or delegation to any Person into or with which Elavon will merge or consolidate, or who may acquire substantially all of Elavon's stock or assets." 7) Section 18.6Arbitration is deleted. 8) Section 18.9 Attorney's Fees is deleted. 9) Section 18.12 Amendments is revised as follows: "Amendments. Except as otherwise provided in the Agreement, amendments to the Agreement will be in writing and signed by the parties. Notwithstanding the foregoing, Elavon and Member may amend or modify the Agreement, to the extent such changes are required by or attributable to changes in the Payment Network Regulations or other Laws, upon written notice to Company. Elavon or Member will inform Company of such a change in a periodic statement or other written notice, and such change will become effective not less than thirty (30) days following the issuance of the notice. Notwithstanding the previous sentence, changes to fees authorized by the Agreement will be effective upon notice to Company, unless a later effective date is provided." USA- GOV -ELV -0218 DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 10) Schedule A, Section 1.8 Title; Quiet Enjoyment is replaced as follows: "Title; Quiet Enjoyment. Lessor will at all times retain title to the Leased Equipment. All documents of title and evidence of delivery will be delivered to Lessor. Lessee hereby authorizes Lessor, at Lessee's expense, to cause the lease or any statement or other instrument in respect to the lease showing the interest of Lessor in the Leased Equipment including Uniform Commercial Code Financing Statements, to be filed or recorded and /or refiled and rerecorded, and grants Lessor the right to execute Lessee's name thereto. Lessee agrees to execute and deliver any statement or instrument requested by Lessor for such purpose, and agrees to pay or reimburse Lessor for any filing, recording or stamp fees or taxes arising from the filing or recording of any such instrument or statement. Lessee will at its expense, protect and defend Lessor's title against all persons claiming against or through Lessee, at all times keep the Leased Equipment free from legal process or encumbrance whatsoever and, will give Lessor immediate notice thereof and will be responsible for any loss caused thereby. Lessee agrees to procure for Lessor, such estoppel certificates, landlord's or mortgagees' waiver or other similar documents as Lessor may reasonably request. Provided Lessee is not in default hereunder, Lessee will quietly use and enjoy the Leased Equipment subject to the terms hereof." 11) Schedule A, Section 1.10 Net Lease; Taxes is replaced as follows: "Net Lease; Taxes. Lessee intends the rental payments hereunder to be net to Lessor, and Lessee agrees to pay any applicable sales, use, excise, personal equipment, stamp, documentary and ad valorem taxes, license and registration fees, assessment, fines, penalties and similar charges imposed on the ownership, possession or use of the Leased Equipment during the term of the lease. Lessee will pay all applicable taxes (except Lessor's federal or state net income taxes) which may be imposed on Lessor or Lessee with respect to the lease payments hereunder or the ownership of the Leased Equipment. Lessee will pay as additional rent, any applicable taxes documented as paid or advanced by Lessor on behalf of Lessee. Lessee will file personal equipment tax returns with respect to the Leased Equipment." 12) Schedule A, Section 1.11 Indemnity is replaced as follows: "Responsibility of Lessor. As between Lessor and Lessee, Lessee will be responsible for, and at its own expense, defend itself against any and all liability, damage or loss, arising out of the ownership, selection, possession, leasing, operation, control, use, condition, maintenance, delivery and return of the Leased Equipment. The obligations herein provided will continue in full force and effect notwithstanding the termination of the lease." 13) Schedule A, Section 1.16 Remedies is replaced as follows: "Remedies. If an Event of Default will occur, Lessor may, at its option, at any time (i) declare immediately due and payable and recover from Lessee, as liquidated damages for the loss of a bargain and not as a penalty, an amount equal to all accrued and unpaid rental payments and late charges, taxes, and other fees, plus the Loss Amount; provided, however, that if an Event of Default will occur as described in Section 1.15(iv) through (vi) above, Lessor without any notice or action will be deemed to have made such a declaration; (ii) automatically charge the DDA for all money amounts owed; (iii) to the extent permitted by applicable Law, without demand or legal process, enter into the premises where the Leased Equipment may be found and take possession of and remove the Leased Equipment, without liability for such retaking; (iv) Lessor may hold, sell or otherwise dispose of any such Leased Equipment at a private or public sale; or (v) exercise any other remedies available under applicable Law. If Lessor takes possession of the Leased Equipment, Lessor will give Lessee credit for any sums received by Lessor from the sale or rental of the Leased Equipment after deduction of the expenses of sale or rental and Lessee will remain liable to Lessor for any deficiency. Notwithstanding the foregoing, to the extent any software included with the Leased Equipment is nontransferable or its transfer restricted, Lessee agrees that Lessor and/or the licensor of such software will have no duty to remarket or otherwise mitigate any damages relating to such software. Lessee will also be responsible for all expenses incurred by Lessor in connection with the enforcement of any of Lessor's remedies including all expenses of repossessing, storing, shipping, repairing and selling the Leased Equipment. Lessor and Lessee acknowledge the difficulty in establishing a value for the unexpired lease term and, owing to such difficulty, agree that the provisions of this Section represent an agreed measure of damages and are not to be deemed a forfeiture or penalty. All remedies of Lessor hereunder are cumulative, are in addition to any other remedies provided for by Law, and may, to the extent permitted by Law, be exercised concurrently or separately. The exercise of any one remedy will not be deemed to be an election of such remedy or to preclude the exercise of any other remedy. No failure on the part of the Lessor to exercise and no delay in exercising any right to remedy will operate as a waiver thereof or modify the terms of the lease." 14) Schedule A, Section 1.19 Miscellaneous is replaced as follows: "Miscellaneous. If Lessee fails to pay any rent or other amount required herein to be paid to Lessor within five (5) days of when due, Lessee agrees to pay Lessor, in addition to the payment, a late charge of 15% of the amount past due (but at least $7.50) for each late payment. Each month the past due payment remains unpaid, an additional late fee in the amount defined will be assessed. Payments are applied to late fees and service charges first and then to the lease obligation. Amounts will be payable in addition to all amounts payable by Lessee to Lessor as a result of exercise of any of the remedies herein provided. If Lessee requests any services not provided for herein, Lessee agrees to pay an applicable fee for delivery of such services. Lessee will inform Lessor of any change in Lessee's name, address, billing address, USA- GOV -ELV -0218 DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 telephone numbers, location of the Leased Equipment, or DDA. If Lessee fails to comply with any provision of the lease, Lessor will have the right, but not be obligated, to affect such compliance on behalf of Lessee upon ten (10) days prior written notice to Lessee. In such event, all monies expended by, and all expenses of Lessor in effecting such compliance, will be deemed to be additional rental, and will be paid by Lessee at the time of the next monthly payment of rent. All notices under the lease will be sufficient if given personally or mailed postage prepaid to the party intended at the respective address set forth herein, or at such other address as said party may provide in writing from time to time. The lease inures to the benefit of and is binding upon the personal representatives, successors and assigns of the parties hereto. Time is of the essence of the lease. Lessor and Lessee intend the lease to be a valid and subsisting legal instrument, and agree that no provision of the lease that may be deemed unenforceable will in any way invalidate any other provision or provisions of the lease, all of which will remain in full force and effect. The lease will be binding when accepted in writing by Lessor and will be governed by the laws of the state where the Leased Equipment is located." 15) Schedule A, Section 1.20 Important Information about Credit Reporting is deleted. 16) Schedule B, Section 1.5 Personal Guaranty is deleted. 17) Schedule B, Section 1.6 Jurisdiction and Venue; Governing Law is deleted. 18) Schedule B, Section 1.7 Arbitration is deleted. USA- GOV -ELV -0218 DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 (Orange County, NC) SECOND ADDENDUM TO THE TERMS OF SERVICE FOR GOVERNMENT 05.14.18 SECOND ADDENDUM TO THE TERMS OF SERVICE FOR GOVERNMENTANSTITUTIONAL COMPANIES This Second Addendum to the Terms of Service for Government/Institutional Companies ( "Second Addendum ") is entered into as of the Second Addendum Effective Date by and among Orange County, NC on behalf of its Health Department ( "Company "), Elavon, Inc. ( "Elavon ") and Member (collectively the "Parties "). The Parties entered into the Terms of Service ( "TOS "), as amended by the Addendum to the Terms of Service for Government/Institutional Companies ( "Addendum;" collectively with the TOS the "Agreement ") and desire to amend it as follows: 1. Capitalized terms used and not otherwise defined in this Second Addendum shall have the meanings ascribed to them in the Agreement or the Operating Guide. Except as specifically set forth in this Second Addendum, all terms and conditions of the Agreement remain in full force and effect as of the Second Addendum Effective Date. 2. Company is agreeing to the Terms of Service dated January 2018. 3. Section 4.1 Security Interests is deleted. 4. Section 4.2(a) Reserve Account is hereby deleted and replaced with the following: (a) Establishment. If a Reserve Event occurs, Elavon may establish a Reserve Account to provide a source of funds to pay Elavon for any amounts owed by Company. The Reserve Account will be maintained with sums sufficient to satisfy Company's current and future obligations as determined by Elavon. Elavon will have sole control of the Reserve Account. Elavon may, at any time, require that the amount on deposit in the Reserve Account be increased. Company's settlement funding may be directed to a Reserve Account if Company's websites are not in compliance with the Payment Network Regulations. The following will constitute "Reserve Events ": (i) Fraudulent activity in any monthly period that equals or exceeds I % of Company's average monthly volume over the preceding 12 -month period; (ii) Chargebacks in any monthly period that equal or exceed I% of the total dollar value of incoming items to Elavon; (iii) Elavon's reasonable belief that Company, if not approved by Elavon to engage in delayed delivery transactions, has accepted deposits but has not delivered the goods or services; (iv) The commencement of a Bankruptcy Proceeding by or against Company; (v) Termination of the Agreement for any reason or the occurrence of an event giving Elavon the right to terminate the Agreement; (vi) Nonpayment of amounts owed by Company to Elavon; (vii) Fines, assessments, or charges imposed or reasonably expected to be imposed by the Payment Networks; (viii) The occurrence of a material adverse change in Company's financial condition; and (ix) Assignment of the Agreement by Company in violation of Section 18.5 of the Agreement. 5. Section 5.2(a) is amended to add the following: (iv) Elavon acknowledges that Company 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 Company's obligations under this Agreement, then this Agreement shall expire without penalty to Company upon 60 days prior written notice (if feasible) to Elavon of the unavailability and non- appropriation of public funds. It is expressly agreed that Company shall not activate this non - appropriation provision for its convenience or to circumvent the requirements of this Agreement, but only as an emergency fiscal measure during a substantial fiscal crisis. In the event of a change in the Company's statutory authority, mandate and/or mandated functions, by state or federal legislative or regulatory action, which adversely affects Company's authority to continue its obligation under this Agreement, then this Agreement shall terminate without penalty to Company upon 60 days prior written notice (if feasible) to Elavon of such limitation or change in Company's legal authority. In the event of any termination, Company remains responsible for items received post - termination that relate to Transactions received prior to termination (for example, Chargebacks). DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 (Orange County, NC) SECOND ADDENDUM TO THE TERMS OF SERVICE FOR GOVERNMENT OS.14.18 6. Section 12.3 Disclaimer of Warranties is hereby deleted. 7. In Section 14, Limitation of Liability, the following is added after the term "Therefore" in the second sentence: "to the extent not prohibited by Article V of the North Carolina State Constitution, ". 8. The following are added to Section 18: 18.19 The maximum amount payable to Elavon for Elavon fees under this Agreement shall not exceed $9,000.00 for the Initial Term. This amount may not be exceeded without a written amendment duly executed by the Parties. Company acknowledges that Elavon will not monitor this amount and will continue to process Transactions from Company, and Company takes sole responsibility to track and seek increases to this amount as necessary to cover all amounts owed under this Agreement. 18.20 By executing this Agreement, Elavon affirms that Elavon is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Elavon certifies that Elavon has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147 - 86.58. Elavon 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 non - 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.oran eg countync. og v/ departments / purchasing_ division /contracts.php.) 18.21 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 11 A and Article 40 of the North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the parties hereto have executed this Second Addendum. ORANGE COUNTY, NC on behalf of the Health Dep ens44ho,>- (COMPANY"): �jbl�,�ut, %iGUMwtI,V'S�d,l1 By:_e3 �anr�� Name: Bonnie Hammersley EL N;Ji(dpr By: 211R1 7 Name: Timothy Miller Title: County Manager Title: Senior vice President Date: 6/14/2018 ( "Second Addendum Effective Date ") M , '` lbRSigned by: By: Timothy Miller Title: Senior vice President DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD /YYYY) I 06/01/2018 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 have ADDITIONAL INSURED provisions or 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 Aon Risk Services Central, Inc. Minneapolis MN office CONTACT NAME: (A/C.NNo. Ext): (866) 283 -7122 A/C No.): (800) 363 -0105 E -MAIL ADDRESS: 5600 west 83rd Street 8200 Tower, Suite 1100 INSURER(S) AFFORDING COVERAGE NAIC # Minneapolis MN 55437 USA INSURED INSURERA: ACE American Insurance Company 22667 U.S. Bancorp INSURER B: EP- MN -L201 INSURER C: 200 S. 6th street Minneapolis MN 55402 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570071482524 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM /DD/ POLICY EXP MM /DD /YYYY LIMITS County Health Department AUTHORIZED REPRESENTATIVE COMMERCIAL GENERAL LIABILITY Attn: Rebecca 7. Crawford 300 W. Tryon Hillsborough NC 27278 USA EACH OCCURRENCE CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED PREMISES Ea occurrence MED EXP (Any one person) PERSONAL & ADV INJURY GEMLAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE PRO - POLICY PRO LOC JECT PRODUCTS - COMP /OP AGG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY ( Per person) ANYAUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLY AUTOS HI RED AUTOS NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE Per accident UMBRELLA LIAB EACH OCCURRENCE AGGREGATE EXCESS LIAB HOCCUI CLAIMS -MADE DED RETENTION WORKERS COMPENSATION AND PER OTH- I EMPLOYERS' LIABILITY y / N STATUTE ER E.L. EACH ACCIDENT ANY PROPRIETOR / PARTNER I EXECUTIVE OFFICER /MEMBER EXCLUDED? ❑ N/A E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT A Cyber Liability EONG25602894002 11/15/2017 11/15/2018 Aggr Limit $10,000,000 Cyber Liability - Primary SIR applies per policy terms & condi ions DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION ©1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2 aD L N 2 O 2 7 N N N OD r- CD 0 r- LO O Z d R V w N U �fr y_ 2L �z Irtr' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Orange County Health Department AUTHORIZED REPRESENTATIVE Attn: Rebecca 7. Crawford 300 W. Tryon Hillsborough NC 27278 USA ©1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2 aD L N 2 O 2 7 N N N OD r- CD 0 r- LO O Z d R V w N U �fr y_ 2L �z Irtr' DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 AC� °® CERTIFICATE OF LIABILITY INSURANCE D06/08/2018D/YVVV) 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. 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 have ADDITIONAL INSURED provisions or 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: Marsh USA Inc. COMMERCIAL GENERAL LIABILITY 333 South 7th Street, Suite 1400 (A/C. No Ext : A/C No), E -MAIL ADDRESS: Minneapolis, MN 55402 -2400 Attn: Minneapolis.CertRequest @marsh.com Fax 212 - 948 -0114 EACH OCCURRENCE $ INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Indian Harbor Insurance Company 36940 INSURED Elavon, Inc. INSURER B DAMAGE TO l Two Concourse Parkway, Suite 800 INSURER C INSURER D, Atlanta, GA 30328 INSURER E PREMISES ( a occurrence) $ INSURER F MED EXP (Any one person) $ COVERAGES CERTIFICATE NUMBER: CHI - 009003969 -01 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS Manashi Mukherjee -W- 4­4- COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO l CLAIMS -MADE 1:1 OCCUR PREMISES ( a occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ PRO- JECT ❑ LOC PRODUCTS - COMP /OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER ANYPROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? N N/A E.L. EACH ACCIDENT $ (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A ERRORS & OMISSIONS ELU152907 -17F 11/15/2017 11/15/2018 Limit: $10,000,000 A FI BOND (CRIME) ELU152907 -17G 11/15/2017 11/15/2018 Limit: $10,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Orange County Dept. of Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Rebecca Crawford THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 300 W Tryon ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee -W- 4­4- @ 1988 -2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD