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HomeMy WebLinkAbout2018-435-E DSS - SHI-ORANGE LLC nonemergency medicaid transportation servicesDocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Contract #68 -1014 SHI- Orange, LLC dba The Stratford Contract # _68 -1014 Fiscal Year Begins_Julyl, 2018_ Endsjune 30, 2019 This contract is hereby entered into by and between the Orange County Department of Social Services (the "County ") and SM- Orange, LLC dba The Stratford (the "Contractor ") (referred to collectively as the "Parties "). The Contractor's federal tax identification number is or Social Security Number is 20- 8037463. 1. Contract Documents: This Contract consists of the following documents (1) This contract (2) The General Terms and Conditions (Attachment A) (3) The Scope of Work, description of services, and rate (Attachment B) (4) Federal Certification Regarding Drug-Free Workplace & Certification. Regarding Nondiscrimination (Attachment C) (5) Conflict of Interest (Attachment D) (6) No Overdue Taxes (Attachment E) (7) Certification of Transportation (Attachment J) (8) State and Local Certifications (Attachment M) (9) Non - Discrimination, Clean Air Act, Clean Water Act (Attachment N) (10) Outcomes and Reporting (Attachment O) (11) Contract Determination Questionnaire These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements or agreements. 2. Precedence Among Contract Documents: In the event of a conflict between or among the terms of the Contract Documents and this Agreement, the terms of this Agreement shall control. In the event of a conflict between or among the terms of the Contract Documents, then the Contract Documents with the highest relative precedence shall prevail. The order of precedence shall be the order of documents as listed in Section 1, above, with Attachment A having precedence over Attachment B and so forth. If there are multiple Contract Amendments, the most recent amendment shall have the highest precedence and the oldest amendment shall have the lowest precedence. 3. Effective Period: This contract shall be effective on July 1, 2018 and shall terminate on June 30, 2019. This contract must be twelve months or less. 4. Contractor's Duties: The Contractor shall provide the services and in accordance with the approved rate as described in Attachment B, Scope of Work, and shall meet the requirements set forth in Attachment O, Outcomes and Reporting. 5. County's Duties: The County shall pay the Contractor in the manner and in the amounts specified in the Contract Documents. The total amount paid by the County to the Contractor under this contract shall not exceed $1. This amount consists of $1 in Federal (CFDA # ), State and County funds, $0 (source of other funds if applicable). [X] a. There are no matching requirements from the Contractor. [ ] b. The Contractor's matching requirement is $ , which shall consist of- In-kind [ ] Cash [ ] Cash and In -kind [ ] Cash and/or In -kind The contributions from the Contractor shall be sourced from non - federal funds. The total contract amount including any Contractor match shall not exceed $1. 6. Reporting Requirements: Contractor shall comply with audit requirements as described in N.C.G.S. § 1.43C -6 -22 & 23 and OMB Circular A -133 and shall disclose all information required by 42 USC 455.104, or 42 USC 455.105, or 42 USC 455.106. Contract-General (07/ 10) Page 1 of 5 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Contract #68 -1014 SM- Orange, LLC dba The Stratford 7. Payment Provisions: Payment shall be made in accordance with the Contract Documents as described in the Scope of Work, Attachment B. 8. Contract Administrators: All notices permitted or required to be given by one Party to the other and all questions about the contract from one Party to the other shall be addressed and delivered to the other Parry's Contract Administrator. The name, post office address, street address, telephone number, fax number, and email address of the Parties' respective initial Contract Administrators are set out below. Either Party may change the name, post office address, street address, telephone number, fax number, or email address of its Contract Administrator by giving timely written notice to the other Party. For the County: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS Lindsey 'Shewmaker, Human Services Manager Lindsey Shewmaker, Human Services Manager Orange County Department of Social Services Change County Department of Social Services P.O. Box 8181 113 Mayo Street Hillsborough, NC 27278 Hillsborough, NC 27278 lshewmaker@orangecountync.gov Shewmaker @orangecountync.gov (919) 245 -2817 (919) 245 -2817 For the Contractor: IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY O'T'HER MEANS Cameron Cook Cameron Cook SHE - Orange, LLC dba The Stratford SHI- Orange, LLC dba The Stratford 400 2 "a Avenue NW 4002 "d Avenue NW Hickory, NC 28601 Hickory, NC 28601 ccook @affinityliyinggroup.com ecook@affiniiylivinggroup.com (828) 270 -4656 (828) 270 -0656 9. No Assignment or Sub - Contract: Contractor shall not sub - contract out any of the services provided for in this Agreement or make any assignment of this Agreement (including rights to payments) without the prior written Consent of the County as specified more fully in Attachment A, General Terms and Conditions. 10. Supplementation of Expenditure of Pubtie Funds: The Contractor assures that funds received pursuant to this contract shall be used only to supplement, not to supplant, the total amount of federal, state and local public funds that the Contractor otherwise expends for contract services and related programs. Funds received under this contract shall be used to provide additional public funding for such services; the funds shall not be used to reduce the Contractor's total expenditure of other public funds for such services. 11. Disbursements: As a condition of this contract, the Contractor acknowledges and agrees to make disbursements in accordance with the following requirements: a. Implement adequate internal controls over disbursements, b. Pre -audit all vouchers presented for payment to determine: i. Validity and accuracy of payment ii. Payment due date iii. Adequacy of documentation supporting payment iv. Legality of disbursement c. Assure adequate control of signature stamps /plates; d. Assure adequate control of negotiable instruments; and Contract- General (07 /10) Page 2 of 5 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Contract #68 -1014 SHI- Orange, LLC dba The Stratford e. Implement procedures to insure that account balance is solvent and reconcile the account monthly, 12. Outsourcing to Other Countries: The Contractor certifies that it has identified to the County all jobs related to the contract that have been outsourced to other countries, if any. The Contractor further agrees that it will not outsource any such jobs during the terra of this contract without providing notice to the County. 13. Federal Certifications: Individuals and Organizations receiving federal funds must ensure compliance with certain certifications required by federal laws and regulations. The contractor is hereby complying with Certifications regarding Nondiscrimination, Drug -Free Workplace Requirements, Environmental Tobacco Smoke, Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions, and Lobbying. These assurances and certifications are to be signed by the contractor's authorized representative. 14. Relationship of the Parties: Contractor is an independent contractor of the County. Contractor represents that it has or will secure, at its own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees of or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized or permitted under state and local law to perform such services. It is further agreed by Contractor that it shall obey all State and Federal statutes, rules and regulations which are applicable to provisions ofthe services called for herein. Neither Contractor nor any employee of the Contractor shall be deemed an officer, employee or agent of the County. 15. Termination: This Agreement may be terminated as specified in Attachment A, General Terms And Conditions. 16. Insurance Requirements: Contractor shall obtain, at its sale expense, all insurance as required in Attachment A, General Terms And Conditions. 17, Indemnification: Contractor agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by Contractor in accordance with Attachment A, General Terms And Conditions. It is the intent of this Section that Contractor indemnify County to the full extent permitted by law. 18. Entire Agreement: The parties have read this Agreement, including the Contract Documents, and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between the parties. 19. Interpretation: When the context in which words are used in this Agreement indicates that such is the intent, words shall in the singular number shall include the plural and vice versa. The masculine gender shall include the feminine and neuter. IN WITNESS WB EREOF, the County and the Contractor have been first duly authorized, have executed and entered into this Agreement as of the day and year first above written. Contract - General (07110) Page 3 of 5 DocuSign Envelope ID: AA1647C8 -6778- 4021- 9E83- EDC4C913A37C "' 0 S g ed by'. T ' T ' "" ` -..tE STRATFORD f,• Wwj y, C563 &S7A1C4C44C... S lgnatUre Charles E. Trefzger, 3r. Printed Name ORANGE COUNTY I EDocuSigned by: 61tiVt.ltr 06379946755E477... tsonme Hammersiey, (:aunty Manager 8/14/2018 Date Manager Title Contract x#68 -1014 SHI- Orange, LLC dba The Stratford 8/20/2018 Date Contract- General (07/10) Page 4 of 5 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C ATTACHMENT A GENERAL TERMS AND CONDITIONS Orange County Department of Social Services Relationships of the Parties Independent Contractor: The Contractor is and shall be deemed to be an independent contractor in the performance of this contract and as such shall be wholly responsible for the work to be performed and for the supervision of its employees. The Contractor represents that it has, or shall secure at its own expense, all personnel required in performing the services under this agreement. Such employees shall not be employees of, or have any individual contractual relationship with the County. Subcontracting: The Contractor shall not subcontract any ofthe work contemplated under this contract without prior written approval from the County. Any approved subcontract shall be subject to all conditions of this contract. Only the subcontractors specified in the contract documents are to be considered approved upon award of the contract. The County shall not be obligated to pay for any work performed by any unapproved subcontractor. The Contractor shall be responsible for the performance of all of its subcontractors. Assignment: No assignment of the Contractor's obligations or the Contractor's right to receive payment hereunder shall be permitted. However, upon written request approved by the issuing purchasing authority, the County may: (a) Forward the Contractor's payment check(s) directly to any person or entity designated by the Contractor, or (b) Include any person or entity designated by Contractor as a joint payee on the Contractor's payment check(s). In no event shall such approval and action obligate the County to anyone other than the Contractor and the Contractor shall remain responsible for fulfillment of all contract obligations. Beneficiaries: Except as herein specifically provided otherwise, this contract shall inure to the benefit of and be binding upon the parties hereto and their respective successors. It is expressly understood and agreed that the enforcement of the terms and conditions of this contract, and all rights of action relating to such enforcement, shall be strictly reserved to the County and the named Contractor. Nothing contained in this document shall give or allow any claim or right of action whatsoever by any other third person. It is the express intention of the County and Contractor that any such person or entity, other than the County orthe Contractor, receiving services or benefits under this contract shall be deemed an incidental beneficiary only. Indemnity and Insurance Indemnification: The Contractor agrees to indemnify and hold harmless the County and any of their officers, agents and employees, from any claims of third parties arising out or any act or omission of the Contractor in connection with the performance of this contract. Insurance: During the term ofthe contract, the Contractor at its sole cost and expense shall provide commercial insurance of such type and with such terms and limits as may be reasonably associated with the contract. As a minimum, the Contractor shall provide and maintain the following coverage and limits: (a) Worker's Compensation - The contractor shall provide and maintain Worker's Compensation Insurance as required by the laws of North Carolina, as well as employer's liability coverage with minimum limits of $500,000.00, covering all of Contractor's employees who are engaged in any work under the contract. If any work is sublet, the Contractor shall require the subcontractor to provide the same coverage for any of his employees engaged in any work under the contract. (b) Commercial General Liability - General Liability Coverage on a Comprehensive Broad Form on an occurrence basis in the minimum amount of $1,000,000.00 Combined Single Limit. (Defense cost shall be in excess of the limit of liability.) (e) Automobile Liability Insurance: The Contractor shall provide automobile liability insurance with.a combined single limit of $500,000.00 for bodily injury and property damage; a limit of $500,000.00 for uninsured/under insured motorist coverage; and a limit of $25,000.00 for medical payment coverage. The Contractor shall provide this insurance for all automobiles that are: (a) owned by the Contractor and used in the performance of this contract; (b) hired by the Contractor and used in the performance of this contract; and (c) Owned by Contractor's employees and used in performance of this contract ("non - owned vehicle insurance "). Non -owned General Terms and Conditions — (06116) Pagel of 5 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C vehicle insurance protects employers when employees use their personal vehicles for work purposes. Dion -owned vehicle insurance supplements, but does not replace, the car - owner's liability insurance. The Contractor is not required to provide and maintain automobile liability insurance on any vehicle — owned, hired, or non -owned -- unless the vehicle is used in the performance of this contract. (d) The insurance coverage minimums specified in subparagraph (a) are exclusive of defense costs. (e) The Contractor understands and agrees that the insurance coverage minimums specified in subparagraph (a) are not limits, or caps, on the Contractor's liability or obligations under this contract. (f) The Contractor may obtain a waiver of any one or more of the requirements in subparagraph (a) by demonstrating that it has insurance that provides protection that is equal to or greater than the coverage and limits specified in subparagraph (a). The County shall be the sole judge of whether such a waiver should be granted. (g) The Contractor may obtain a waiver of any one or more of the requirements in paragraph (a) by demonstrating that it is self - insured and that its self- insurance provides protection that is equal to or greater than the coverage and limits specified in subparagraph (a). The County shall be the sole judge of whether such a waiver should be granted. (h) Providing and maintaining the types and amounts of insurance or self- insurance specified in this paragraph is a material obligation of the Contractor and is of the essence of this contract. (i) The Contractor shall only obtain insurance from companies that are authorized to provide such coverage and that are authorized by the Commissioner of Insurance to do business in the State of North Carolina. All such insurance shall meet all laws of the State of North Carolina. {j) The Contractor shall comply at all times with all lawful terms and conditions of its insurance policies and all lawful requirements of its insurer. (k) The Contractor shall require its subcontractors to comply with the requirements of this paragraph. (1) The Contractor shall demonstrate its compliance with the requirements of this paragraph by submitting certificates of insurance to the County before the Contractor begins work under this contract. Transportation of Clients by Contractor: The contractor will maintain Insurance requirements if required as noted under Article 7 Rule R2 -36 of the North Carolina Utilities Commission. Default and Termination Termination Without Cause: The County may terminate this contract without cause by giving 34 days written notice to the Contractor. Termination for Cause: If, through any cause, the Contractor shall fail to fulfill its obligations under this contract in a timely and proper manner, the County shall have the right to terminate this contract by giving written notice to the Contractor and specifying the effective date thereof. In that event, all finished or unfinished deliverable items prepared by the Contractor under this contract shall, at the option of the County, become its property and the Contractor shall be entitled to receive just and equitable compensation for any satisfactory work completed on such materials, minus any payment or compensation previously made. Notwithstanding the foregoing provision, the Contractor shall not be relieved of liability to the County for damages sustained by the County by virtue of the Contractor's breach of this agreement, and the County may withhold any payment due the Contractor for the purpose of setoff until such time as the exact amount of damages due the County from such breach can be determined. In case of default by the Contractor, without limiting any other remedies for breach available to it, the County may procure the contract services from other sources and hold the Contractor responsible for any excess cost occasioned thereby. The filing of a petition for bankruptcy by the Contractor shall be an act of default under this contract. Waiver of Default: Waiver by the County of any default or breach in compliance with the terms of this contract by the Provider shall not be deemed a waiver of any subsequent default or breach and shall not be construed to be modification of the terms of this contract unless stated to be such in writing, signed by an authorized representative of the County and the Contractor and attached to the contract. Availability of Funds: The parties to this contract agree and understand that the payment of the sums specified in this contract is dependent and contingent upon and subject to the appropriation, allocation, and availability of funds for this purpose to the County. Force Majeure: Neither party shall be deemed to be in default of its obligations hereunder if and so long as it is prevented from performing such obligations by any act of war, hostile foreign action, nuclear explosion, riot, strikes, civil insurrection, earthquake, hurricane, tornado, or other catastrophic natural event or act of God. Survival of Promises: All promises, requirements, terms, conditions, provisions, representations, guarantees, and warranties contained - herein shall survive the contract expiration or termination date unless specifically provided General Terms and Conditions — (06/16) Page 2 of 5 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C otherwise herein, or unless superseded by applicable Federal or State statutes of limitation_ Intellectual Property Rights Copyrights and Ownership of Deliverables: All deliverable items produced pursuant to this contract are the exclusive property of the County. The Contractor shall not assert a claim of copyright or other property interest in such deliverables. Federal Intellectual Property Bankruptcy Protection Act: The Parties agree that the County shall be entitled to all rights and benefits of the Federal Intellectual Property Bankruptcy Protection Act, Public Law 100 -506, codified at 11 U.S.C. 365 (n) and any amendments thereto. Compliance with Applicable Laws Compliance with Laws: The Contractor shall comply with all laws, ordinances, codes, rules, regulations, and licensing requirements that are applicable to the conduct of its business, including those of federal, state, and local agencies having jurisdiction and/or authority. 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. Title VI, Civil Rights Compliance: In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs. Equal Employment Opportunity: The Contractor shall comply with all federal and State laws relating to equal employment opportunity. Health Insurance Portability and Accountability Act (HI[PAA): The Contractor agrees that, if the County determines that some or all of the activities within the scope of this contract are subject to the Health Insurance Portability and Accountability Act of 1996, P.L. 104 -91, as amended ( "HIPAA "), or its implementing regulations, it will comply with the HIPAA requirements and will execute such agreements and practices as the County may require to ensure compliance. (a) Data Security: The Contractor shall adopt and apply data security standards and procedures that comply with all applicable federal, state and local laws, regulations, and rules. (b) Duty to Report: The Contractor shall report a suspected or confirmed security breach to the local Department of Social Services Contract Administrator within twenty -four (24) hours after the breach is first discovered, provided that the Contractor shall report a breach involving Social Security Administration data or Internal Revenue Service Data within one (1) hour after the breach is first discovered. (c) Cost Borne by Contractor: If any applicable federal, state, or local law, regulation or rule requires the Contractor give written notice of a security breach to affected persons, the Contract shall bear the cost of the notice. Trafficking Victims Protection Act of 2000: The Contractor will comply with the requirements of Section 106(8) of the Trafficking Victims Protection Act of 2000, as amended (22 U.S.C. 7104) Executive Order # 24: It is unlawful for any vendor, contractor, subcontractor or supplier of the state to make gifts or to give favors to any state employee. For additional information regarding the specific requirements and exemptions, contractors are encouraged to review Executive Order 24 and G.S. Sec. 133 -32. Confidentiality Confidentiality: Any information, data, instruments, documents, studies or reports given to or prepared or assembled by the Contractor under this agreement shall be kept as confidential and not divulged or made available to any individual or organization without the prior written approval of the County. The Contractor acknowledges that in receiving, storing, processing or otherwise dealing with any confidential information it will safeguard and not further disclose the information except as otherwise provided in this contract. Oversight Access to Persons and Records: The State Auditor shall have access to persons and records as a result of all contracts or grants entered into by State agencies or political subdivisions in accordance with General Statute 147 -64.7. Additionally, as the State funding authority, the Department of Health and Human Services shall have access to persons and records as a result of all contracts or grants entered into by State agencies or political subdivisions. General Terms and Conditions — (06116) Page 3 of 5 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Record Retention: records shall not be destroyed, purged or disposed of without the express written consent of the Division. State basic records retention policy requires all grant records to be retained for a minimum of five years or until all audit exceptions have been resolved, whichever is longer. If the contract is subject to federal policy and regulations, record retention may be longer than five years since records must be retained for a period of three years following submission of the final. Federal Financial Status Report, if applicable, or three years following the submission of a revised final Federal Financial Status Report. Also, if any litigation, claim, negotiation, audit, disallowance action, or other action involving this Contract has been started before expiration of the five -year retention period described above, the records must be retained until completion of the action and resolution of all issues which arise from it, or until the end of the regular five -year period described above, whichever is later. The record retention period for Temporary Assistance for Needy Families (TANF) and MEDICAID and Medical Assistance grants and programs must be retained for a minimum of ten years. Warranties and Certifications Date and Time Warranty: The Contractor warrants that the product(s) and service(s) furnished pursuant to this contract ("product' ' includes, without limitation, any piece of equipment, hardware, firmware, middleware, custom or commercial software, or internal components, subroutines, and interfaces therein) that perform any date and/or time data recognition function, calculation, or sequencing will support a four digit year format and will provide accurate date/time data and leap year calculations. This warranty shall survive the termination or expiration ofthis contract. Certification Regarding Collection of Taxes: G. S. 143- 59.1 bars the Secretary of Administration from entering into contracts with vendors that meet one of the conditions of G.S. 105- 164.8(b) and yet refuse to collect use taxes on sales of tangible personal property to purchasers in North Carolina. The conditions include: (a) maintenance of a retail establishment or office; (b) presence of representatives in the State that solicit sales or transact business on behalf of the vendor; and (c) systematic exploitation of the market by media - assisted, media- facilitated, or media - solicited means. The Contractor certifies that it and all of its affiliates (if any) collect all required taxes. E- 'verify Pursuant to G. S. 143 -48.5, the undersigned hereby certifies that the Contractor named below, and the Contractor's subcontractors, complies with the requirements ofArticle 2 of Chapter 64 of the NC General Statutes. Miscellaneous Choice of Law: The validity of this contract and any of its terms or provisions, as well as the rights and duties of the parties to this contract, are governed by the laws of North Carolina. The Contractor, by signing this contract, agrees and submits, solely for matters concerning this Contract, to the exclusive jurisdiction of the courts of North Carolina and agrees, solely for such purpose, that the exclusive venue for any legal proceedings shall be grange County, North Carolina. The place of this contract and all transactions and agreements relating to it, and their situs and forum, shall be Orange County, North Carolina, where all matters, whether sounding in contract or tort, relating to the validity, construction, interpretation, and enforcement shall be determined. Amendment: This contract may not be amended orally or by performance. Any amendment must be made in written form and executed by duly authorized representatives of the County and the Contractor. Severability: In the event that a court of competent jurisdiction holds that a provision or requirement of this contract violates any applicable law, each such provision or requirement shall continue to be enforced to the extent it is not in violation of law or is not otherwise unenforceable and all other provisions and requirements of this contract shall remain in full force and effect. Headings: The Section and Paragraph headings in these General Terms and Conditions are not material parts of the agreement and should not be used to construe the meaning thereof. Time of the Essence: Time is of the essence in the performance of this contract. Key Personnel: The Contractor shall not replace any of the key personnel assigned to the performance of this contract without the prior written approval of the County. The term "key personnel" includes any and all persons identified as such in the contract documents and any other persons subsequently identified as key personnel by the written agreement of the parties. Care of Property: The Contractor agrees that it shall be responsible for the proper custody and care of any property furnished to it for use in connection with the performance of this contract and will reimburse the County for loss of, or damage to, such property. At the termination of this contract, the Contractor shall contact the County for General Terms and Conditions — (06/16) Page 4 of 5 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C instructions as to the disposition of such property and shall comply with these instructions. Travel Expenses: Reimbursement, if provided in this Agreement, to the Contractor for travel mileage, meals, lodging and other travel expenses incurred in the performance of this contract shall not exceed the rates established in County policy. Sales/Use Tax Refunds: If eligible, the Contractor and all subcontractors shall: (a) ask the North Carolina Department of Revenue for a refund of all sales and use taxes paid by them in the performance of this contract, pursuant to G.S. 105- 164.14; and (b) exclude all refundable sales and use taxes from all reportable expenditures before the expenses are entered in their reimbursement reports. Advertising: The Contractor shall not use the award of this contract as a part of any news release or commercial advertising. Orange County Living Wage: Orange County is committed to providing its employees with a living wage and encourages agencies to which it provides funding to pursue the same goal. The County's living wage hourly standard, as adopted by the Orange County Board of County Commissioners annually, can be found in the Orange County Budget Ordinance. To the extent possible, Orange County recommends that the Contractor and all subcontractors provide a living wage, as defined in this section, to their employees. Signatures: This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. General Terms and Conditions — (06/16) Page 5 of 5 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C ATTACHMENT B SCOPE OF WORT{ Grange County Department of Social. Services Federal Tax Id. or SSN 20- 8037463 Contract ## 68 -1014 A. CONTRACTOR. INFORMATION 1. Contractor Agency Name: S111- Orange, LLC dba The Stratford 2. If decent from Contract Administrator Information in General Contract: Address Telephone Number: Fax Number: Email: 3. Name of Program (s): Medicaid Transportation 4. Status: ( } Public () Private, Not for Profit (X) Private, For Profit 5. Contractor's Financial Reporting Year July 1, 2018 through June 30, 2019 B. Explanation of Services to be provided and to whom (include SIS Service Code): _ The Contractor will rovin ide transportation services to client(, identified by the CouM. The Contractor will transport client(s) to and from medical appointments. The Contractor is required to meet all goals and outcomes listed in Attachment O. C. Rate per unit of Service (define the unit): 1. If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart) 2. Negotiated County Rate. See rate letter attached. D. Number of units to be provided: E. Details of Billing Process and Time Frames: Billing and reimbursement processes will be handled through the NC Tracks system, rather than through the County. The Contractor must submit information through NC Tracks in order to receive reimbursement for services provided. F. Area to be served/Delivery site(s): Orange, Alamance, Durham, Wake, and Chatham Counties Dom Signed by: N Wou DAE1E196A83B455._ — Nancy Coston, Social Services Director 8/14/2018 (Date Submitted) DacuSigned by: C5B3 &67A1C4C44C... (Signature of Contractor) 8/14/2018 (Date Submitted) Contract -Scope of Work (46/04) Page lof 1 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Hf 1 INITY Uvir)g Post Office Box 2568 Hickory, North Carolina 28603 -2568 May 18, 2018 To: Orange County Fr: Affinity Living Group Re: 2018 -19 NEMT Rates, Stratford House To Whom it May Concern: Our Mileage rate for the 2018 -2019 Contract year is $2.33 per mile:. Regards, Cameron Cook Transportation Manager Affinity Living Group Corporate Office 328 First Avenue Nei', Hickory, North Carolina 28601 Tel: 828322.5535 ■ Fax: 828.326.8115 + www.afiinitylivingroup.com DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C ATTACHMENT C CERTIFICATION REGARDING DRUG -FREE 'WORKPLACE REQUIREMENTS AND CERTIFICATION REGARDING NONDISCRIMINATION Orange County Department of Social Services I. By execution of this Agreement the Contractor certifies that it will provide a drug -free workplace by: A. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the Contractor's workplace and specifying the actions that will be taken against employees for violation of such prohibition; B. Establishing a drug -free awareness program to inform employees about: (1) The dangers of drug abuse in the workplace; (2) The Contractor's policy of maintaining a drug -free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; C. Making it a requirement that each employee be engaged in the performance of the agreement be given a copy of the statement required by paragraph (A); D. Notifying the employee in the statement required by paragraph (A) that, as a condition of employment under the agreement, the employee will: (1) Abide by the terms of the statement; and (2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction; E. Notifying the County within ten days after receiving notice under subparagraph (D)(2) from an employee or otherwise receiving actual notice of such conviction; F. Taking one of the following actions, within 30 days of receiving notice under subparagraph (D)(2), with respect to any employee who is so convicted: (1) Taking appropriate personnel action against such an employee, up to and including termination; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or Iocal health, law enforcement, or other appropriate agency; and Making a good faith effort to continue to maintain a drug -free workplace through implementation of paragraphs (A), (B), (C), (D), (E), and (F). Federal Certification - Drug -Free Workplace & Nondiscrimination rev. 06 -2015 Page 1 of 2 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C H. The site(s) for the performance of work done in connection with the specific agreement are listed below: 1. 2. (Street address) (City, county, state, zip code) (Street address) (City, county, state, zip code) Contractor will inform the County of any additional sites for performance of work under this agreement. False certification or violation of the certification shall be grounds for suspension of payment, suspension or termination of grants, or government -wide Federal suspension or debarment 45 C.F.R. Section 82.510. Section 4 CFR Part 85, Section 85.615 and 86.620. CERTIFICATION REGARDING NONDISCRDAINATION The Vendor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88 -352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. § §1681 -1683, and 1685 - 1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. § §6101- 6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92 -255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91 -616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism.; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. § §3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i) the requirements of any other nondiscrimination statutes which may apply to this Agreement. OocuSigned by: f. C5B3687A1C4C44C... Signature Manager Title SHI - Orange, LLC 8/14/2018 Agency /Organization Date (Certification signature should be same as Contract signature.) Federal Certification - Drug -Free Workplace & Nondiscrimination rev. 06 -2015 Page 2 of 2 DocuSign Envelope ID: AA1647C8 -8778- 4021- 9E83- EDC4C913A37C ATTACHMENT D Conflict of interest Policy The Board of DirectorsfTrustees or other governing persons, officers, employees or agents are to avoid any conflict of interest, even the appearance of a conflict of interest. The Organization's Board of Directors/Trustees or other governing body, officers, staff and agents are obligated to always act in the best interest of the organization, This obligation requires that any Board member or other governing person, officer, employee or agent, in the performance of Organization duties, seek only the furtherance of the Organization mission. At all times, Board members or other governing persons, officers, employees or agents, are prohibited from using their job title, the Organization's name or property, for private profit or benefit. A. The Board members or other governing persons, officers, employees, or agents of the Organization should neither solicit nor accept gratuities, favors, or anything of monetary value from current or potential contractors /vendors, persons receiving benefits from the Organization or persons who may benefit from the actions of any Board member or other governing person, officer, employee or agent. This is not Intended to preclude bona -flde Organization fund raising - activities. B. A Board or other governing body member may, with the approval of Board or other governing body, receive honoraria for lectures and other such activities while not acting in any official capacity for the Organization. Officers may, with the approval of the Board or other governing body, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay, Employees may, with the prior written approval of their supervisor, receive honoraria for lectures and other such activities while on personal days, compensatory time, annual leave, or leave without pay. if a Board or other governing body member, officer, employee or agent Is acting in any official capacity, honoraria received in connection with activities relating to the Organization are to be paid to the Organization, C, No Board member or other governing person, officer, employee, or agent of the Organization shall participate in the selection, award, or administration of a purchase or contract with a vendor where, to his knowledge, any of the following has a financial interest In that purchase or contract; 1. The Board member or other governing person, officer, employee, or agent; 2. Any member of their family by whole or half blood, step or personal relationship or relative -in -law; 1 An organization in which any of the above Is an officer, director, or employee; 4. A person or organization with whom any of the above Individuals is negotiating or has any arrangement concerning prospective employment or contracts. D. Duty to Disclosure -- Any conflict of interest, potential conflict of interest, or the appearance of a conflict of interest is to be reported to the Board or other governing body or one's supervisor Immediately. E. Board Action — When a conflict of interest is relevant to a matter requiring action by the Board of Directors/Trustees or other governing body, the Board member or other governing person, officer, employee, or agent (person(s)) must disclose the existence of the conflict of interest and be given the opportunity to disclose all material facts to the Board and members of committees with governing board delegated powers considering the possible conflict of interest. After disclosure of all material facts, and after any discussion with the person, he/she shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon. The remaining board or committee members shall decide if a conflict of interest exists. in addition, the person(s) shall not participate in the final deliberation or decision regarding the matter under consideration and shall leave the meeting during the discussion of and vote of the Board of Directors/Trustees or other governing body. F. Violations of the Conflicts of Interest Policy -- If the Board of Directors/Trustees or other governing body has reasonable cause to believe a member, officer, employee or agent has failed to disclose actual or possible conflicts of interest, it shall inform the person of the basis for such belief and afford the person an opportunity to explain the alleged failure to disclose. If, after hearing the person's response and after Rev. 06 -07 -2015 DocuSign Envelope ID: AA1647C8 -6778- 4021- 9E83- EDC4C913A37C making further investigation as warranted by the circumstances, the Board of Directors/Trustees or other governing body determines the member, officer, employee or agent has failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective action. G. Record of Conflict -- The minutes of the governing board and all committees with board delegated powers shall contain: 1. The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. 2. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. Approved by: SHI -Oran i- G ' me 111'11rgpnz 'tiara Signature cif Organization fficial A& Da e NOTARIZED CONFLICT OF INTEREST POLICY State of North Carolina County of /311RO I, rCtC4kd /3 �� YCrI Notary Public for said County and State, certify that TQ—grzao? 21- acknowledged - personally appeared before me this day and that he/she is 1M410IC6t of N - dRst G� GG 'L [enter name of entity] and by that authority duly given and as the act of the Organization, affirmed that the foregoing Conflict of Interest Policy was adopted by the B and of Directors/Trustees or other governing body in a meeting held on the 4r* day of vw .x0119 . Sworn to and subscribed before me this y r4' day of / �, �- 6� {Official Seal} My Commission expires It NIL- IL- ,?,Z Rev. 06-07-2015 �z A04 �y�t�iidBdiYtr ©r N `,51, C7 _ C() , MY c f " ryq ublic 800 'ZI it G r ���1lii1111 ►�5 DocuSign Envelope ID: AA1647C8 -6778- 4021- 9E83- EDC4C913A37C Attachment E -- No Overdue Tax Debts SHI - Orange 0610412018 To: Orange County Department of Social Services /Human Services Certification: We certify that SHI - Orange does not have any overdue tax debts, as defined by N.C.G.S. 105- 243.1, at the federal, State, or local level. We further understand that any person who snakes a false statement in violation of N.C.G.S. 1430- 6 -23(c) is guilty of a criminal offense punishable as provided by N.C.G.S.) 143C -10 -1 b. Sworn Statement: Charles E. Trefzger, Jr. and Shana Gebelein being duly sworn, say that we are the Board Chair and V.P. of Finance, respectively, of The Stratford of Chapel Hill in the State of North Carolina; and that the foregoing certification is true, accurate and complete to the hest of our knowledge and was, made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authdrities for further action. Chair Cl�of Financ Sworn to and subscribed before me on the day of the date of said certification. My Commission Expires. � (Notary Signature and Seal) co U i ",, w I G.S. 105 -243.1 defines: Overdue tax debt. -- Any part of a tax debt that remains unpaid 90 days or more after the notice of final assessment was mailed to the taxpayer. The terns does not include a tax debt, however, If the taxpayer entered Into an installment agreement for the tax debt under G.S. 105-237 within 90 days after the notice of final assessment was malted and has not failed to make any payments due under the installment agreement." Page 1 of 1 Rev. 6 -7 -2015 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C ATTACHMENT J CERTIFICATION REGARDING TRANSPORTATION Orange County Department of Social Services By execution of this Agreement the Contractor certifies that it will provide safe client transportation by: 1. Insuring that all drivers (including employees, contractors, contractor's employees, and volunteers) shall be at least 18 years of age; 2. Insuring that all drivers (including employees, contractors, contractor's employees, and volunteers) shall be licensed to operate the specific vehicle used in transporting clients in accordance with Chapter 20 -7 of the General Statutes of North Carolina and the Division of Motor Vehicle requirements; 3. Insuring that all vehicles transporting clients shall have at least the minimum level of liability insurance appropriate for the type of vehicle as defined by Article 7, Rule 112 -36 of the North Carolina Utilities Commission; 4. Insuring that the contractor shall have written policies and procedures regarding how drivers handle and report client emergencies and/or vehicle crashes involving clients to contractor and how contractor notifies the Orange County Department of Social Services; S. Insuring that no more than one quarter of one percent of all trips be missed by the contractor during the course of the contract period; (Medicaid only) 6. Insuring that that no more than five percent (S %) of trips should be late for recipient drop off to their appointment per month; (Medicaid only) 7. Contractor will maintain records documenting the following (County may require contractor to provide): a. Valid current copies of Drivers License for all drivers; b. Current valid Vehicle Registration, for all vehicles transporting clients; c. Driving records for all drivers for the past three years and with annual updates; d. Criminal Background checks through North Carolina Law Enforcement or NCIC prior to employment and every three years thereafter; e. Alcohol and Drug Testing policy to meet the Federal Transit Authority guidelines. 8. Disclosing, at the outset of the contract, upon renewal and upon request, any criminal convictions or other reasons for disqualifications from participation in Medicare, j (oacusi X,4 ti ;,-a;A e%r T;t1P "Shier v3rograms (signature on this form confirms this statement). f'• �` l .1�' • Manager C §636S7A1C4C44C... - Signature Title SHI - Orange, LLC 8/14/2018 Agency /Organization Date (Certification signature should be same as Contract signature.) Transportation Certification (06116) Page I of 1 DocuSign Envelope ID: AA1647C8 -8778- 4021- 9E83- EDC4C913A37C Medicaid Transportation Provider Documentation North Carolina Orange County Department of Social Services Organization Information Organization Name as shown on income tax return, SHE - Oranne, LLC EIN 20- 8037463 Doing Business As (DBA) information DBAName The Stratford EIN Same Former DSA Name(s) NIA EIN NIA Former OBA Name(s) NIA EIN NIA Years Doing Business under Current Name n0 08 Years Doing Business under Previous Names) NIA Ownership Information How would you describe the ownership? (circle one) Sole Proprietor Partnership Corporation Clty/Miunicipality Non - Profit For Corporation, Partnership, or Non - Profit: P lease provide ownership infonnatlon for each owner who has direct or indirect ownership or control Interest of 5% or more in the organization or entity. Owner 1 Full Name (Last, first, Middle) WT AL Holdings, LL.0 SSN or EIN 81-3458026 Date of Birth (MMIDDICCYY) NIA __ Business Relationship to NEMT Provider Sole Member Familial Relationship to NEW Provider (Mother, Father, Sister, Brother, None, etc.) None Owner 2 Full Name (Last, first, Middle) SSN or EIN Date of Birth (MMIDDICCYY) Business Relationship to NEMT Provider Familial Relationship to NEW Provider (Mother, Father, Sister, Brother, None, etc.) Owner 3 Full Name (Last, first, Middle) SSN or EIN Date of Birth (MMIDDICCYY) Business Relationship to NEW Provider Familial Relationship to NEW Provider (Mother, Father, Sister, Brother, None, etc.) Owner 4 Full Name (Last, first, Middle) SSN or EIN Date of Birth (MMI❑❑ICCYY) Business Relationship to NEW Provider Familial Relatlonshlp to NEW Provider (Mother, Father, Sister, Brother, None, etc.) Managing Relationships As required by 42 CFR 1002.31 Non Emergency Medical Pfovlders must disclose the following for each individual officer, director, managing employee (general manager, business manager, administrator) and Electronic Funds Transfer (EFT) authorized Individual. Falture to provide the required Information may result in a denial for participaCon. Relationship 1 Full Name (Last, first, Middle) Tret -ger, Charles Edward Jr. Social Security !Number 226.04 -4773 Date of Blrth (MM1Dt71CCYY) 0712611958 _Business Relationship to NEMT Provider Manager Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc.) None Relationship 2 Full !Name (last, first, Middle) Social Security Number Date of Birth (MMIDDICCYY) Business Relationship to NEW Provider Familial Relationship to NEW Provider (Mother, Father, Sister, Brother, None, etc,) DMA -3124 (revised 6!6112) DocuSign Envelope ID: AA1647C8 -8778- 4021- 9E83- EDC4C913A37C Full Name (Last, firs 1, Middle) Social Security Number. Date of Birth (MMIDD /CCYY) Business Relationship to NEW Provider Familial Relationship to NEMT Provider (Mather, Father, Sister, Brother, None, etc.) Relationship 4 Full Name (Last, first, Middle) Social Security Number. Date of Birth (MM1DD /CCYY) Business Relationship to NEW Provider Familial Relationship to NEMT Provider (Mother, Father, Sister, Brother, None, etc. By my signature, I attest that none of the Individuals Identified above have ever been convicted of: • A criminal offense related to the delivery of an Item or service under Medicare, Medicaid, or any skate health care program; • Medleare /Medlcald or any other healthcare program fraud; • A conviction related to padent/client abuse; • A felony conviction related to a controlled substance occurring after August 1996. r Name Charles_ E._Tref7ger, Jr. Signature a Date 06/04/18 h!W://oig,hhs.gov/exclusions/index.as n Results of OIG Federal Inquiry: Circle One; No Match Found Organization or Business Owner Manager Name of Individuallentlty which resulted in an exclusion match Exclusion Code Transportation Coordinator/Designee Signature IittAS: //p roviderttacking ,dhhs,state.nc.us/defattlt,aspxx Results of NC DHHS Provider Penalty Tracking Database Circle One: No Match Found SSN Owner Name of owner and/or S S N of owner which resulted In an exclusion match Exclusion Reason (Action issued} Transportation CoordinatorlDesignee Signature /DMA -5124 (revised 615112) DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C ATTACHMENT M STATE AND LOCAL CERTIFICATION Contractor Certifications Required by North Carolina Law Orange County Department of Social Services Instructions The person who signs this document should read the text of the statutes listed below and consult with counsel and other knowledgeable persons before signing. • The text of Article 2 of Chapter 64 of the North Carolina General. Statutes can be found online at: http: / /www.ncga. state. nc. us/ EnactedLegislation /'StattrtesfPDFByArtiele /Chapter 64 /Article_2.pdf * The text of G.S. 105- 164.8(b) can be found online at: http: / /www.ncga. state. nc. us/ EnactedLegislationIStatutes/ PDF/ BySection /Chapter_105 /GS_105- 164.8.pdf • The text of G.S. 143 -48.5 (S.L. 2013 -418, s. 2.(d)) can be found online at: http: / /www.tiega.state.nc.us /Sessions / 2013 /B i l ls/House /PDF/H786v6.pdf • The text of G.S. 143 -59.1 can be found online at: http://www.ncg:a.state.ne.us/EnactedLegislation/Statutes/PDF/B • The text of G.S. 143 -59.2 can be found online at: http: / /www.ncga. state. nc. us /Enacted Legislation /Statutes /PDF /BySection/Chapter 143/GS_1.43- 59.2.pdf • The text of G.S. 147- 33.95(g) (S.L. 2013 -418, s. 2. (e)) can be found online at: httn: / /www.ncea.state.nc. us/ Sessions /2013 /Bills /House/PDF /H786v6.vdf • The text of Orange County Living Wage Contractor Policy which is attached to this document. Certifications (1) Pursuant to G.S. 143 -45.5, the undersigned hereby certifies that the Contractor named below, and the Contractor's subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC General Statutes, including the requirement for each employer with more than 25 employees in North Carolina to verify the work authorization of its employees through the federal E- Verify system." E- Verify System Link: www.uscis.gov Local government is specifically exempt from Article 2 of Chapter 64 of the North Carolina General Statutes. However, local government is subject to and must comply with North Carolina General Statute § 153A- 99.1., which states in part as follows: Counties Must Use E- Verify. - Each county shall register and participate in E- Verify to verify the work authorization of new employees hired to work in the United States. (2) Pursuant to G.S. 143- 59.1(h), the undersigned hereby certifies that the Contractor named below is not an "ineligible Contractor" as set forth in G.S. 143- 59.1(a) because: (a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of Contractor Certifications Required by North Carolina Law Page I of 3 revised May 30, 2018 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or more of the conditions of G.S. 145- 164.8(b); and (b) [check one of the following boxes] ❑ Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven country" as set forth in G.S. 143- 59.1(c) (2) after December 31, 2001; or ❑ The Contractor or one of its affiliates has incorporated or reincorporated in a "tax haven country" as set forth in G.S. 143- 59.1(c)(2) after December 31, 2001 but the United States is not the principal market for the public trading of the stock of the corporation. incorporated in the tax haven country. (3) Pursuant to G.S. 143- 59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors, or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years immediately prior to the date of the bid solicitation. (4) The undersigned hereby certifies further that: (a) He or she is a duly authorized representative of the Contractor named below; (b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the Contractor; and (c) He or she understands that any person who knowingly submits a false certification in response to the requirements of G.S. 143-59. land -59.2 shall be guilty of a Class I felony. (5) Pursuant to the Orange County Living Wage Contractor's Policy: (a) The undersigned certifies that the Contractor pays the employees who perform services under this contract a living wage (in Orange County currently $14.25 per/hr.) Check here ❑ if contractor pays employees performing under this contract a living wage. If Contractor does not pay employees a living wage, what is the wage that employees performing services under this contract paid SHI - Orange, LLC DacuSigned by: ,s 'e. �`v � ►fit r°, . - e5B36s7A1C4C44C... Signature of Contractor's Authorized Agent Charles E. Trefzger, Jr. DocuSigned by: 'Contractor's Authorized Agent C6555B39335247A... signature or w imess Mel Deaton Printed Name of Witness 8/14/2018 Date Manager Title Executive Assistant 'ritle 8/20/2018 Date The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document immediately thereafter. Contractor Certifications Required by North Carolina Law Page 2 of 3 revised May 30, 2018 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Section I: General Government and Administration Policy 10.0: Living Wage Contractor Policy Reviewed by: County Attorney /County Manager Approved by: County Manager Original Effective Date: April 21, 2016 Revisions: Policy Statement It is the policy of Orange County to ensure its employees, and all individuals who provide services for Orange County, are paid a living wage. Purpose To encourage all vendors and contractors to pay a living wage to all employees who perform work pursuant to a contract with Orange County. Amlicabitity Applies to all Orange County contracts and purchases. Policy 10.1 Living Wage 10.1.1 Orange County is committed to providing its employees with a living wage and encourages all contractors and vendors doing business with Orange County to pursue the same goal. Orange County's living wage is $14.25 per hour. To the extent possible, Orange County recommends that contractors and vendors seeking to do business with Orange County provide a living wage to their employees_ 10.1.2 Prior to final execution of a contract with Orange County all contractors and vendors seeking to do business with Orange County shall submit to the County's representative a statement indicating whether those employees who will perform work on the Orange County contract are paid at least the living wage amount set out above. If such employees do not make at least the living wage amount set out above the contractor or vendor shall indicate in the statement the actual amount paid to such employees. For bid projects this statement should be submitted as part of the bid packet. This policy may he reviewed annually and updated as needed by the Manager's Office Contractor Certifications Required by North Carolina Law Page 3 of 3 revised May 30, 2018 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Contract #68 -1014 SHI- Orange, LLC dba The Stratford ATTACHMENT N Orange County Department of Social Services/Human Services CERTIFICATION REGARDING NONDISCRiM1NATION, CLEAN AIR ACT, CLEAN WATER ACT Certification Regarding Nondiscrimination The Contractor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88 -352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C.,§ §1681 -1683, and 1685 - 1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. § §6101- 6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92 -255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91 -616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. § §3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i) the requirements of any other nondiscrimination statutes which may apply to this Agreement. The Contractor must comply with Executive Order 11246, entitled "Equal Employment Opportunity," as amended by Executive Order 11375, and as supplemented by the Department of Labor Regulations (41 CFR Part 60): The Executive Order prohibits federal contractors and federally- assisted construction contractors and subcontractors who do over $10,000 in Government business in one year from discriminating in employment decisions on the basis of race, color, religion, sex, or national origin. The Executive Order also requires Government contractors to take affirmative action to ensure that equal opportunity is provided in all aspects of their employment. Meaningful Access for LEP Individuals: The Contractor that participate in the SNAP must tape reasonable steps to ensure that LEP persons have meaningful access to programs, services, and benefits. This includes the requirement to provide bilingual program information and certification materials and interpretation services to single language minorities in certain project areas. SNAP Contractors that do not provide meaningful access for LEP individuals risk violating prohibitions against discrimination based on National Origin in the Food and Nutrition Act of 2008, as amended, Title VI of the Civil Rights Act of 1964 (Title VI) and SNAP program regulations at 7 CFR 272A(b). They also risk noncompliance with the USDA policy guidance titled, "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination. Affecting Limited English Proficient Persons ", published in 79 FR 70771 - 70784 (November 28, 2014). The Contractor should develop an implementing plan to address the language assistance needs of the LEP population served. This may include contracting for oral interpretation services, hiring bilingual staff, arranging telephone interpreters and/or language lines, coordinating community volunteers, translating vital documents, and providing written notice that language services are available in appropriate languages. Quality and accuracy of the language service is (Federal Certification- Nan - Discrimination, Clean Air, Clean Water) (01 /2018)Page 1 of 4 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Contract 468 -I014 SHI- Orange, L:LC dba The Stratford critical in order to avoid serious consequences to the LEP person and to the recipient. LEP needs should be considered in developing budgets and front line staff should understand how to obtain language assistance services. For additional assistance and information regarding LEP matters, please also visit hn://www.lep.gov. Ensuring Equal Opportunity Access for Persons with Disabilities: The Contractor must also ensure equal opportunity access for persons with disabilities. This includes ensuring that communications with applicants, participants, members of the public, and companions with disabilities are as effective as communications with people without disabilities. Contractors that do not provide persons with disabilities equal opportunity access to programs may risk violating prohibitions against disability discrimination in the Rehabilitation Act of 1978, the American with Disabilities Act (ADA) of 1990, as amended, and SNAP program regulations. DOJ published revised final regulations implementing Title H and Title HI of the ADA on September 15, 2010. These regulations are codified at 28 CFR Part 35 "Nondiscrimination on the Basis of Disability in State and Local Government Services" and at 28 CFR Part 36 "Nondiscrimination on the Basis of Disability in Public Accommodations and Commercial Facilities ". in accordance with the implementing regulations, Contractors must provide auxiliary aids and services where necessary to ensure effective communication and equal opportunity access to program benefits for individuals with disabilities. The type of auxiliary aids and services required will vary, but a Contractor may not require an individual with a disability to bring another individual to interpret, and may rely on a person accompanying a disabled individual only in limited circumstances. When a Contractor communicates with applicants and beneficiaries by telephone, it must provide text telephone services (ITY) or have access to an equally effective electronic telecommunications system to communicate with individuals who are deaf, hard of hearing, or hearing impaired. Contractors must also ensure that interested persons, including persons with impaired vision or hearing, can obtain information as to the existence and location of accessible services, activities, and facilities. For more information, please visit the ADA website: http: / /www.ada.gov. IV. The Clean Air Act, Section 306; 42 U.S.C. §7441 et seq. (1970) a. No Federal agency may enter into any contract with any person who is convicted of any offense under section 113(c) for the procurement of goods, materials, and services to perform such contract at any facility at which the violation which gave rise to such conviction occurred if such facility is owned, leased, or supervised by such person. The prohibition in the preceding sentence shall continue until the Administrator certifies that the condition giving rise to such a conviction has been corrected. For convictions arising under section 113(c)(2), the condition giving rise to the conviction also shall be considered to include any substantive violation of this Act associated with the violation of 113(c)(2). The Administrator may extend this prohibition to other facilities owned or operated by the convicted person. b. The Administrator shall establish procedures to provide all Federal agencies with the notification necessary for the purposes of subsection (a). c. In order to implement the purposes and policy of this Act to protect and enhance the quality of the Nation's air, the President shall, not more than 180 days after enactment of the Clean Air Amendments of 1970 cause to be issued an order (1) requiring each Federal agency authorized to enter into contracts and each Federal agency which is empowered to extend Federal assistance by way of grant, loan, or contract to effectuate the purpose and policy of this Act in such contracting or assistance activities, and (2) (Federal Certification - Non - Discrimination, Clean Air, Clean Water) (0112018)Page 2 of 4 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C Contract #68 -1014 SHI- Orange, LLC dba The Stratford setting forth procedures, sanctions, penalties, and such other provisions, as the President determines necessary to carry out such requirement. d. The President may exempt any contract, loan, or grant from all or part of the provisions of this section where he determines such exemption is necessary in the paramount interest of the United States and he shall notify the Congress of such exemption. e. The President shall annually report to the Congress on measures taken toward implementing the purpose and intent of this section, including but not limited to the progress and problems associated with implementation of this section. [42 U.S.C. 76061 V. The Clean Water Pict; 33 U.S.C. §1251 et seq. (1972) a. No Federal agency may enter into any contract with any person who has been convicted of any offense under Section 309(c) of this Act for the procurement of goods, materials, and services if such contract is to be performed at any facility at which the violation which gave rise to such conviction occurred, and if such facility is owned, leased, or supervised by such person. The prohibition in preceding sentence shall continue until the Administrator certifies that the condition giving rise to such conviction has been corrected. b. The Administrator shall establish procedures to provide all Federal agencies with the notification necessary for the purposes of subsection (a) of this section. c. In order to implement the purposes and policy of this Act to protect and enhance the quality of the Nation's water, the President shall, not more than 180 days after the enactment of this Act, cause to be issued an order: (i) requiring each Federal agency authorized to enter into contracts and each Federal agency which is empowered to extend Federal assistance by way of grant, loan, or contract to effectuate the purpose and policy of this Act in such contracting or assistance activities, and (ii) setting forth procedures, sanctions, penalties, and such other provisions, as the President determines necessary to carry out such requirement. d. The President may exempt any contract, loan, or grant from all or part of the provisions of this section where he determines such exemption is necessary in the paramount interest of the United States and he shall notify the Congress of such exemption. e. The President shall annually report to the Congress on measures taken in compliance with the purpose and intent of this section, including, but not limited to, the progress and problems associated with such compliance. f. No certification by a contractor, and no contract clause, may be required in the case of a contract for the acquisition of commercial items in order to implement a prohibition or requirement of this section or a prohibition or requirement issued in the implementation of this section. g. In paragraph (1), the term "commercial item" has the meaning given such term in section 4(12) of the Office of Federal Procurement Policy Act (41 U.S.C. 403(12)). (Federal Certification - Non - Discrimination, Clean Air, Clean Water) (0112018)Page 3 of 4 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C OacuSigned by: �5 f'• 'I �`]] manager C563B87A1C4044C.... Signature Title SHI - Orange, LLC 8/14/2018 Agency /Organization Date (Certification signature should be same as Contract signature.) Contract 468 -1014 SH1- Orange, LLC dba The Stratford (Federal Certification - Non - Discrimination, Clean Air, Clean Water) (0112018)Page 4 of 4 DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C ATTACHMENT Q OUTCOMES AND REPORTING Orange County Department of Social Services By signing and submitting this document, the Contractor certifies that it agrees to the following. 1. The Contractor agrees to participate in program, fiscal and administrative monitoring and/or audits, making records and staff time available to Federal, State and County staff. 2. The Contractor agrees to take necessary steps for corrective action, as negotiated within a corrective action plan, for any items found to be out of compliance with Federal, State, and County laws, regulations, standards and/or terms of the Contract. 3. The Contractor agrees that continuation of and/or renewal of this Contract is contingent on meeting the following requirements. The Contractor agrees to A. Adhere to all Federal and State transportation laws & regulations. B. Transport clients) to and from medical appointments as requested by the County. C. Transport approved, authorized client(s) to specified destinations within and outside of Change County upon request, on time, and in accordance with arrangements made by the County. D. Transport clients only to approved destinations. Any additional destinations cannot be provided without the expressed consent and authorization of the County. E. Provide services to enrolled participants within three days of a request. F. Provide critical services on short notice when requested. G. Coordinate maintenance with private vendors to ensure vehicles are in safe operating order. H. Discuss the specific situation, and present evidence of cause, with the County prior to termination of services for any client. 1. Complete the DMA 5124 as park of the annual contract process. J. Only submit invoices for trips approved by the County. Trips included on invoices that were not pre - approved will not be reimbursed. K. Meet on -time performance standards such that no more than 5 % of trips should be late for client drop -off to his appointment per month. Late is defined as past the client's appointment time. L. Not miss more than one quarter of one percent of all trips during the course of the contract year. M. Report all no -shows on a daily basis and cancellations on a monthly basis to the County. N. Record all client complaints which deal with the matters under the control of Contractor, including the date of the complaint, the nature of the complaint, and what steps were taken to resolve the complaint. O. Provide names of all owners, managers, management entities, and subcontractors. P. Report any changes such as insurance provider, business ownership or management. Q. Disclose, at the outset of the contract, upon renewal and upon request, any criminal convictions or other reasons for disqualifications from participation in Medicare, Medicaid or Title XX DocuSigned by: �,(A A►'�r,s f . W Y, Y, C5636S7A1C4C44C... Signature SHI - Orange, LLC Agency /Organization Manager Title 8/14/2018 Date (Certification signature should be same as Contract signature.) Outcomes (06/04) Page 1 of 1 DocuSign Envelope ID: AA1647C8 -8778- 4021- 9E83- EDC4C913A37C f� AMLIV -01 RESJEI f��" DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 0a1o21201s 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 C A cT Jessica Reiser Alliance Insurance Group Arlc N , Mdj: (AIC, No), 941 Oak St. . es.reiser allianceins r com Euctene, OR 97401 E I ] 9 P• INSURED The Stratford LLC 405 Smith Level Rd Chapel Hill, NC 27516 �nt,r�oArcc rCOVIVIrA'TC MJIUCar -D• RFVICIArd NIIM RFR- 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 ADDL SUBR POLICYNUMBER POLICYEFF POLICY EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY X CLACMSlu1AmE OCCUR X $25,000 Deductible X NSC100326 0810112018 08101/20/9 EACH OCCURRENCE 1,000,000 DAM AGE TO RENTED urreGoj $_ _ 200,406 ME EXP (Any one arson 5,000 I PERSONAL &ADV INJURY 1,000,000 X Per Claim GENERAL AGGREGATE 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; POLICY E] .wa F—x] LOC PRODUCTS - COMPIOPAGG 31000MO ANNUAL AGGREGAT 151000,000' OTHER: A OMOBILE LIABILITY UT COMBINED SINGLE LIMIT 11000,000 BODILY INJURY Per arson X ANY AUTO x 0337309 -09- 125201 08101/2018 0810112019 OWNED SCHEDULED AU��IT��O$ ONLY AUTOS SOOlLY INJURY Paraccldent $ _RoP c dent 11E IS �p '_ Ai1T�1S ONLY AUTOS ONNLY rx $ C X UMBRELLALIAB OCCUR EACH OCCURRENCE 6,000,000 EXCESS LIA® CLAIMS-MADE X J 2USC30405502 0810112018 08101 {2019 X 6RGREGATE 6,000,000 DED X , RETENTION$ 26,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PRgO�PR IETORIPARTNEWEXECUTIVE {AMandatary In NH} EXCLUDED? N/A PER OTH- Es - -$� E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE E.L. DISEASE - POLICY LIMIT If yes, des -tribe under DESCRIPTION OF OPERATIONS below A General Liability - NSC100326 08101/2018 OB10112019 $1M Per Incident/Agg _ 3,000,000 A PL Deductible • E NSC100326 0810112018 08101.12019 Per Claim 25,000 DESCRIPTION Or OPERATIONS ✓' LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be atlacbed It more space Is requlred) Coverage placed with National Fire & Marine Insurance Company are Issued pursuant to the surplus lines law and does not have the protection of state guaranty or insolvency funds nor has the policy wording been reviewed by the insurance department of the state. Terrorism Coverage Is Included. UMBRELLA COVERAGE IS EXCESS OVER: General & Professional Liability, Employee Benefits, Auto Liability, and Employers Liability. SEE ATTACHED ACORD 101 Orange County Local Government PO Box 8181 Hillsborough, NC 27278 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE jl�lt 4 ACORD 25 (2016103) @ 1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: AA1647C8 -B778- 4021- 9E83- EDC4C913A37C AGENCY CUSTOMER ID: AFFILIV -01 LOC #: 4 A illl� "R130 ADDITIONAL REMARKS SCHEDULE AGENCY Alliance Insurance Group POLICY NUMBER SEE PAGE 1 CARRIER SEE PAGE 1 NAMED INSURED The Stratford LLC 405 Smith Level Rd'. Chapel Hill, NC 27516 NAIC CODE SEE P 1 EFFECTIVE DATE: REISJ E1 Page 1 of 1 AUDI I I©NAL KtIYIAKKJ THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Cert[flcate of Liability Insurance Description of Operations/Locations /Vehicles: Sexual & Physical AbuselMolestation is an included coverage under the professional liability for a healthcare event with limits of $1,000,000 Per Event/$3,000,000 Aggregate Limits Orange County Local Government is listed as addtional insured, as per contract, in regards to their interest in the location and the fallowing vehicle: 2010 . Dodge Grand Caravan SXT Sport Van VIN: 2D4RN5D18AR409690 ACORD 101 (2008101) V "LUU8 AGUKU t;UKF iJKAI1UN. AN rignis reservea. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: AA1647C8 -6778- 4021- 9E83- EDC4C913A37C AFFIL IV -011 CREESE CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 08/0112018 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(les) 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 to the certificate holder In lieu of such endorsement(s). _rights PRODUCER Alliance Insurance Group 941 Oak St. Eugene, OR 97401 CONTACT Rene Zeller NAME' ___ ONE TFA-X A /C, No, Ft); 1048 1 INC. No :(545 ) 404 -2539 rena.zoller @allianceinsgrp.com INSURE S AFFORDING COVERAGE N IC # INSURER A:Berkshire Hathaway Insurance Group MED EXP Ana rson INSURED INSURER 5: INSURER C: NOB I LLC Affinity Living Group LLC PO Box 2568 INSURER D; _ PRODUCTS - COMPIOP 62G Hickory, NC 28643 INSURER £: INSURER F; rcorrerrArc REVISION NUMRFR: 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- CLAIMS. IN SR ADDL Su8Rr POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ❑ POLICY NUMBER D. LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE E:] OCCUR EACH OCCURRENCE DAMAGE TO RENTED MED EXP Ana rson PERSONAL & ADV I JURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY—] Ta El LOC OTHER: GENERAL AGGREGATE PRODUCTS - COMPIOP 62G AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS y�+ p HJff S ONLY AUTOS ONLY COMBINE[- SINGLE LIMIT dF BODILY INJURY Per Person BODILY INJURY Per accident) $ Ige4a dent AMAGE UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE OEO RETENTION S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROP RIETORIPARTNE RIEXECUTIVE gFFfCEWMEMFR EXCLUDED? (Mandatory in NH] If yes, describe under DES CRIPTION'OF OPERATIONS below NIA OWC910252 08101/2018 0810112019 X PER OTII E.L. EACH ACCIDENT 1,000,000 E.L. DISEASE -EA EMPLOYE 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES ACORD 101, Additional Remarks Schedule, may be attached If more space is required) The Stratford LLC 405 Smith Level Rd Chapel Hill NC 27516 Orange County Local Government PO Box 8181 Hillsborough, NC 27278 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016148) (0 9988 -2015 AUUKU c:UKPUKA I IUN. All rignis reservea. The ACORD name and Toga are registered marks of ACORD