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Home My WebLink About2018-494-E Health - Triangle Urology vasectomy servicesDocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 [Departmental Use Only] TITLE TriangleUrology- Steriliz. FY 2018 -2019 ORANGE COUNTY CONTRACT UNDER $5,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this 1 st day of July, 2018, ( "Effective Date ") by and between Orange County, North Carolina, a body politic and corporate organized under the laws of the State of North Carolina, (the "County "), party of the first part; and Triangle Urology Associates, P.A. (the "Provider "), party of the second part; WITNESSETH: For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby contracts for the services of the Provider, and the Provider agrees to provide the following services to the County in accordance with the terms of this Agreement, time being of the essence: The services and/or materials and/or construction (hereinafter referred to collectively as "Services ") to be furnished under this Agreement are as follows: Provider will perform vasectomy and post - procedure semen analysis to uninsured males referred by Orange County Health Department. OCHD will pay Provider $850 per procedure performed inclusive of the post - precedure semen analysis. The term of this agreement rendered shall be from July 1, 2018 to June 30, 2019. Provider represents and agrees that Provider is qualified to perform and fully capable of performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner to the satisfaction of the County. Provider shall be responsible for all errors or omissions, in the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the County. Provider agrees that Provider shall not sub - contract any of the services to be provided in this Agreement, nor shall Provider assign any right or responsibility granted or required by this Agreement, without the prior written approval of the County. SPECIFIC TERMS 1. Payment: The County agrees to pay at the rates specified for Services satisfactorily performed in accord with this Agreement. The amount to be paid by the County shall not exceed Three thousand four hundred dollars, ($3,400). Payment shall be made within thirty (30) days of an invoice properly submitted to County. Should Provider fail to perform its duties under the terms of this Agreement, County may, without fault or penalty, withhold any payment associated with the work to be performed until such time as said work is completed. 2. Non — waiver: Failure by County at any time to require the performance by Provider of any of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of this Non - Waiver Clause. 3. Independent Contractor: The Provider shall operate as an independent contractor, and the County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider. 4. Insurance: Provider shall obtain, at its sole expense, Commercial General Liability Insurance, Automobile Insurance, Workers' Compensation Insurance, and any additional insurance as may Revised 10/17 (Mgr appry 5k 6/18) DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 be required by County's Risk Manager as such insurance requirements are described in the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements (each document is incorporated herein by reference and may be viewed at http: / /www.orangecountync.gov /departments /purchasing division / contracts.php). If County's Risk Manager determines additional insurance coverage is required such additional insurance shall be designated here N/A (if no additional insurance required mark N/A as being not applicable). Provider shall not commence work until such insurance is in effect and certification thereof has been received by the County's Risk Manager. 5. Indemnity: The Provider agrees, without limitation, to defend, indemnify, and hold harmless Orange County from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable attorney's fees) arising from bodily injury, including death, to any person or persons or damage to or destruction of any property caused in whole or in part by any negligent or intentional act or omission on the part of the Provider in carrying out Provider's duties and obligations related to the Services to be provided in this Agreement. 6. Termination: This Agreement may be terminated at any time by mutual written agreement of the parties or by the County upon written notice to the Provider. County may suspend this Agreement upon reasonable notice to Provider. 7. Entire Agreement and Signatures: The parties have read this Agreement and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between the parties unless and until modified in writing and signed by the parties. Modifications may be evidenced by telefacsimile signature. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent of the Parties to utilize electronic signatures and the intent of the parties to comply with Article I IA and Article 40 of North Carolina General Statute Chapter 66. 8. Governing Law and Priority: Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina and Orange County. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti - discrimination laws, policies, rules, and regulations and the Orange County Non - Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http: / /www.oran eg countync. og v/ departments /purchasing_ division /contracts.php.). Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider certifies that Provider 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. By executing this Agreement Provider certifies that Provider 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 - 86.81. By executing this Agreement Provider affirms Provider is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. In determining the basic services to be provided, should any documents be referenced in or attached to this Agreement, the terms herein shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. 9. Dispute Resolution: Neither party may initiate binding arbitration. Any disputes shall be resolved by nonbinding mediation. If such mediation fails either party may initiate litigation to resolve the dispute. Should either parry initiate litigation to settle any dispute involving the terms of this Agreement such litigation shall be initiated in the General Court of Justice of North Carolina seated in Orange County, North Carolina. Revised 10/17 (Mgr appry 5k 6/18) 2 DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 10. Non Appropriation: Provider acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County's obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non - appropriation of public funds. IN WITNESS WHEREOF, Orange County and the Provider have signed this Agreement, effective as of the day first written above. 0 KM C0j;NTY By: �fc wavy Department erector 200 S. Cameron St. P.O. Box 8181 Hillsborough, NC 27278 Revised 10/17 (Mgr appry 5k 6/18) PR 1DX'Red by: Vaviv, f jV' v, By: Title: Triangle Urology Associates, P.A. 205 Frasier Street Durham, NC 27704 DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 The Hanover Insurance Group.. WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 32 WORKERS COMPENSATION RENEWAL INFORMATION PAGE RENEWAL OF WZ6- AO04288 -04 CORRIFR CnnF NA 3(1937 Policy Number Policy Period Coverage is Provided in the Agency Code From To WZ6- AO04288 -05 06/25/2018 06/25/2019 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 11 EM 1. Named Insured and Address Agent Telephone: 844 - 367 -7899 TRIANGLE UROLOGY ASSOCIATES PA ASSUREDPARTNERS OF NC LLC ATTN: DAVIN BROWN CL HANOVER CSC /STE 350 205 FRASIER ST 4505 FALLS OF NEUSE RD DURHAM, NC 27704 RALEIGH, NC 27609 Federal ID No. 561205950 SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER WORKPLACES NOT SHOWN ABOVE. IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE. ENTITY OF INSURED - CORPORATION ITEM 2. POLICY PERIOD- 06/25/18 TO 06/25/19 12:01 AM STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN. ---------------------------------------------------------------------------------- ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW'AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES - NC. -------------------------------------------------------------------- B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT -------------------------------------------------------------------- C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A. D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING PART OF THIS POLICY. ITEM 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. --------------------------------------------------------------------- - - - - -- CLASSIFICATION OF OPERATIONS EST ANNUAL I PREMIUM SEE ATTACHED SCHEDULE OF OPERATIONS MINIMUM PREMIUM $261 EXPENSE CONSTANT PREMIUM FOR TERRORISM PREMIUM FOR CATASTROPHE TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM' 1,812 210 $44 $73 $2,139 $2,139 COUNTERSIGNED THIS DAY OF - - - - - - - - - - - - - - - AUTHORIZED REPRESENTATIVE BRANCH OFFICE:13840 BALLANTYNE CORP PL SUITE 100 CHARLOTTE NC 28277 IF THE BILL FOR YOUR POLICY IS NOT ENCLOSED, IT WILL BE SENT TO YOU SEPARATELY. 00084form 331 -0226 (9 -03) Date Issued: 03/27/2018 WC000001 B ORIGINAL /INSURED Payment Type: CUST SERV CTR- DIRECT BILL WCDECI DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 The Li C11 iwvwl Insurance Group.. WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 32 EXTENSION OF INFORMATION PAGE RENEWAL OF WZ6- A004288 -04 rAPPIFR rf)nF NO RAM7 Policy Number Policy Period Coverage is Provided in the Agency Code From To WZ6- A004288 -05 06/25/2018 06/25/2019 THE HANOVER AMERICAN INSURANCE COMPANY i 1902820 ITEM 1. Named Insured and Address TRIANGLE UROLOGY ASSOCIATES PA ATTN: DAVIN BROWN 205 FRASIER ST DURHAM, NC 27704 Federal ID No. 561205950 POLICY ** A D D I T I 0 N A L PAGE 2 LOCATION NUMBER Agent Telephone: 844 - 367 -7899 ASSUREDPARTNERS OF NC LLC CL HANOVER CSC /STE 350 4505 FALLS OF NEUSE RD RALEIGH, NC 27609 L O C A T I O N S ** SCHEDULE PAGE 1 Fill 1111 :41 1-1 -------------------------------------------------------------------- 001 205 FRASIER STREET DURHAM NC 27704 -------------------------------------------------------------- - - - - -- y 00084 orm 331 -0226 (9 -03) Date Issued: 03/27/2018 WC000001 B ORIGINAL /INSURED Payment Type: CUST SERV CTR- DIRECT BILL WCDECi DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 Hanover Insurance Group.. WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 32 EXTENSION OF INFORMATION PAGE RENEWAL OF WZ6- AO04288 -04 CARRIER CODE NO 30937 Policy Number Policy Period Coverage is Provided in the Agency Code From To WZ6- A004288 -05 06/25/2018 06/25/2019 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 ITEM 1. Named Insured and Address TRIANGLE UROLOGY ASSOCIATES PA ATTN: DAVIN BROWN 205 FRASIER ST DURHAM, NC 27704 Federal ID No. 561205950 POLICY ** S C H E D U L E PAGE 3 Agent Telephone: 844 - 367 -7899 ASSUREDPARTNERS OF NC LLC CL HANOVER CSC /STE 350 4505 FALLS OF NEUSE RD RALEIGH, NC 27609 OF O P E R A T I O N S ** SCHEDULE PAGE 1 ITEM 4. CLASSIFICATION OF OPERATIONS EST RATE EST ST LOCT CODE TYP TOT -ANN PER$100 ANNUAL Y NO RSK REMUNERATION PREMIUM ---------------------------------------------------------------------------- - - - - -- NC 001 8832 H PHYSICIAN & CLERICAL PREMIUM SUBJECT TO MODIFICATION 0930 PREMIUM FOR WAIVER OF SUBROGATION 9807 PREMIUM FOR INCREASED COV B LIMITS 9848 BALANCE TO MINIMUM FOR COV B LIMITS 9887 NC SCHEDULE MODIFICATION 0032 LOSS CONSTANT 734,2001 .27 .050'i .00801 .8401 I --------- - - - - -- TOTAL - FOR - NORTH - CAROLINA----------------------- I - - - - -- TOTAL SCHEDULE OF OPERATIONS PREMIUM 9740 TERRORISM .0061 9741 CATASTROPHE (OTHER THAN TERRORISM) .0101 ---------------------------------------------------------------- - - - - -- R 00084 orm 331 -0226 (9 -03) ate Issued: 03/27/2018 $1,982 1,982 100 16 59 345 - 0 ------ 1,812- $1,812 44 73 WC000001 B ORIGINAL /INSURED Payment Type: CUST SERV CTR- DIRECT BILL WCDECI DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 The anover Insurance Group.. WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 32 EXTENSION OF INFORMATION PAGE RENEWAL OF WZ6- AO04288 -04 CARRIFR r0DF NO Rn927 Policy Number Policy Period Coverage is Provided in the Agency Code NC From To AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT 06/25/18 WZ6- A004288 -05 06/25/2018 06/25/2019 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 ITEM 1. Named Insured and Address TRIANGLE UROLOGY ASSOCIATES PA ATTN: DAVIN BROWN 205 FRASIER ST DURHAM, NC 27704 Federal ID No. 561205950 POLICY* E N D 0 R S E M E N T / F O R M PAGE 4 STATE NUMBER Agent Telephone: 844- 367 -7899 ASSUREDPARTNERS OF NC LLC CL HANOVER CSC /STE 350 4505 FALLS OF NEUSE RD RALEIGH, NC 27609 S C H E D U L E ** SCHEDULE PAGE 1 EFFECTIVE DATE ---------------------------------------------------------------------------------- NC *000308 0484 PARTNERS, OFFICERS AND OTHERS EXCLUSION END. 06/25/18 NC *000424 0117 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT 06/25/18 NC *320301CO114 NORTH CAROLINA AMENDED COVERAGE ENDT 06/25/18 NC *000414 0790 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT 06/25/18 NC *000419 0101 PREMIUM DUE DATE ENDORSEMENT 06/25/18 NC *000422BO115 TRIPRA DISCLOSURE ENDORSEMENT 06/25/18 NC X000311AO891 VOLUNTARY COMP. & EMPL. LIAB. COV. END. 06/25/18 NC *000313 0484 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 06/25/18 NC *O0000000115 WORKERS COMP AND EMPLOYERS LIABILITY INS POLICY 06/25/18 NC *000404 0484 PENDING RATE CHANGE END. 06/25/18 NC *000421DO115 CATASTROPHE (NON - TERRORISM) PREMIUM ENDT 06/25/18 00085 orm 331 -0226 (9 -03) Date Issued: 03/27/2018 WC000001 B ORIGINAL /INSURED Payment Type: CUST SERV CTR- DIRECT BILL WCDECI �� nanvvG. DocuSign Envelope ID: 5D924F8F OA84 4ECE 95C8- E82E8DA18036 Insurance Group - AVENUES BUSINESSOWNERS DECLARATION BUSINESSOWNERS RENEWAL DECLARATIONS RENEWAL OF OD6 A005679 Policy Number Policy Period Coverage is Provided in the From To 190282000 OD6- A005679 -05 x/25/2018 06/25/2019 MASSACHUSETTS BAY INSURANCE COMPANY Named Insured and Address 844-367-7899 Agent Agent TRIANGLE UROLOGY ASSOCIATES, ASSUREDPARTNERS OF NC LLC ATTN: DAVIN CL HANOVER CSC /STE 350 205 FRASIER ST. 4505 FALLS OF NEUSE RD DURHAM, NC 27704 RALEIGH, NC 27609 Policy Period: Beginning and Ending at 12:01 a.m. Standard Time at the Location of the Described Premises. Business Type: CORPORATION (SINGLE). Mortgagee /Loss Payable: SEE ADDITIONAL INTEREST SCHEDULE Business of the Named Insured: OFFICE. In consideration of the premium, insurance is provided the Named Insured with hicheatspec f cs premises d w Limit Of Insurance sshon, Schedule below and with respect to those coverages and kinds of property subject to all of the terms of this policy including f LOCATION SCHEDULE made a part hereof: ms and endorsements Described Premises: NO. 001 001 205 FRASIER ST., DURHAM, NC 27704 NO. 002 001 10321 LUMLEY RD. # 201, RALEIGH, NC 27617 NO. 003 001 101 CONNER DRIVER, SUITE 201, CHAPEL HILL, NC 27514 Business Income ACTUA Excluded / None / 24 hours 14B hours /72 hours Business Income Waltrin �Period 48 HOURS LIMITS OF INSURANCE LIABILITY Liability and Medical Expenses Limits of Insurance: Except for Damage to Premises Rented to You, each paid tlo aiSECTION II - LIABILITY, D. LIABILITY the AND MED CALnEXPENSES following coverages reduce provide during the applicable annual period. Please refer LIMITS OF INSURANCE, paragraph.4. of the Businessowners Coverage Form. $ 2 , 000, 000 Aggreqate. 1,000,000 Per Occurrence Liability and Medical Ex enses Limit 10,000 Each Person Medical Ex enses lama a to Premises Rented to You $ 000 All Perils 500, INSURED Payment Type: OUST SERV CTR- DIRECT BILL ate Issued: 05/13/2018 ORIGINAU 003404 Page 1 of 2 391 -1002 08 16 LIMITS OF INSURANCE SECTION I - PROPERTY L No 002 Bldg No 001 c Bldg No 001 No 013 Loc No 001 Bldg No 001 oc 000 Deductible Amount $ 1,000 $ 1,000 NOT COVERED NOT COVERED Building Amount $ 2,825,207 Valuation RC 540,750 129, $ 780 $ 189,000 RC Business Personal Property Valuation $ RC RC L BUSINESS LOSS SUSTAINED NOT EXCEEDING 12 CONSECUTIVE MONTH Business Income ACTUA Excluded / None / 24 hours 14B hours /72 hours Business Income Waltrin �Period 48 HOURS LIMITS OF INSURANCE LIABILITY Liability and Medical Expenses Limits of Insurance: Except for Damage to Premises Rented to You, each paid tlo aiSECTION II - LIABILITY, D. LIABILITY the AND MED CALnEXPENSES following coverages reduce provide during the applicable annual period. Please refer LIMITS OF INSURANCE, paragraph.4. of the Businessowners Coverage Form. $ 2 , 000, 000 Aggreqate. 1,000,000 Per Occurrence Liability and Medical Ex enses Limit 10,000 Each Person Medical Ex enses lama a to Premises Rented to You $ 000 All Perils 500, INSURED Payment Type: OUST SERV CTR- DIRECT BILL ate Issued: 05/13/2018 ORIGINAU 003404 Page 1 of 2 391 -1002 08 16 DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 Medical Mutual" PROTEc'r1NG OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend, or alter the coverage afforded by the policies listed below. INSURED: Triangle Urology Associates PA 205 Frasier St Durham, NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh, NC 27609 TYPE OF INSURANCE: Medical Professional Liability - Claims Made POLICY NUMBER: PG113371 RETROACTIVE DATE: March 1, 1978 POLICY PERIOD: FROM: January 1, 2018;12:01 A.M. TO: January 1, 2019;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM 3,000,000 ANNUAL AGGREGATE 5,000,000 Date: October 25, 2017 Authorized presentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM09 (01116) OF NORTH CAROLINA SPRATLT DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 :w Medical Mutual PROTECTING OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend, or alter the coverage afforded by the policies listed below. INSURED: Edward Ross Houser, II, MD 205 Frasier St Durham, NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh, NC 27609 TYPE OF INSURANCE: Medical Professional Liability - Claims Made POLICY NUMBER: PG113371 RETROACTIVE DATE: July 19, 2010 POLICY PERIOD: FROM: January 1, 2018;12:01 A.M. TO: January 1, 2019;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 Date: October 25, 2017 Authorized presentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM09 (01/16) OF NORTH CAROLINA SPRAnT DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 Medical Mutualr. r cc��^^^'.: ��G- y�r.+ c€€ i,; c�E% �: iz2�'.. w��n. �:. F✓ 2�5, ��^ �t:'+ i. 7�, n.# 1stN'. E�' Cea.. cLeFVblsvRJ�." 4q��Y' lte` Pl-.` uF„` �s: v. �a' 7G✓. S.. rY� .l£�%'r'��kbr�.a�'2,°:J:?el�Z�x �:aH,�3!'n�.- X�.,.: .:� PROTECTING OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend, or alter the coverage afforded by the policies listed below. INSURED: Samuel Fong -Yin Huang, MD 205 Frasier St Durham, NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh, NC 27609 TYPE OF INSURANCE: Medical Professional Liability - Claims Made POLICY NUMBER: PG113371 RETROACTIVE DATE: September 3, 2002 POLICY PERIOD: FROM: January 1, 2018;12:01 A.M. TO: January 1, 2019;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 Date: October 25, 2017 Authorized presentative Certificate Holder. MEDICAL MUTUAL INSURANCE COMPANY PM09 (01 /16) OF NORTH CAROLINA SPRATLT DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 i >- Medical Mutual' PROTECTING OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend, or alter the coverage afforded by the policies listed below. INSURED: Jay Han Kim, MD 205 Frasier St Durham, NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh, NC 27609 TYPE OF INSURANCE: Medical Professional Liability - Claims Made POLICY NUMBER: PG113371 RETROACTIVE DATE: July 8, 1996 POLICY PERIOD: FROM: January 1, 2018;12:01 A.M. TO: January 1, 2019;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 Date: October 25, 2017 Authorized presentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM09 (01/16) OF NORTH CAROLINA SPRATLT DocuSign Envelope ID: 5D924F8F- OA84- 4ECE- 95C8- E82E8DA18036 r E. Medical Mutual PROTECTING OUR PROFESSION CERTIFICATE OF INSURANCE This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend, or alter the coverage afforded by the policies listed below. INSURED: Jason R Rothman, MD 205 Frasier St Durham, NC 27704 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh, NC 27609 TYPE OF INSURANCE: Medical Professional Liability - Claims Made POLICY NUMBER: PG113371 RETROACTIVE DATE: August 1, 2009 POLICY PERIOD: FROM: January 1, 2018;12:01 A.M. TO: January 1, 2019;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 3,000,000 5,000,000 Date: October 25, 2017 Authorized presentative Certificate Holder: MEDICAL MUTUAL INSURANCE COMPANY PM09 (01/16) OF NORTH CAROLINA SPRATLT