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HomeMy WebLinkAbout2018-668-E Health - Planned Parenthood professional services agreement DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 PROFESSIONAL SERVICES AGREEMENT THIS PROFESSIONAL SERVICES AGREEMENT (the "Agreement") is made and entered into by and between Orange County, North Carolina, a body politic and political subdivision of the State of North Carolina on behalf of the Orange County Health Department (hereinafter referred to as the "OCHD"), and Planned Parenthood South Atlantic Inc., a North Carolina nonprofit corporation (hereinafter referred to as "PPSAT") and is effective the 5t1i day of October, 2018 (the "Effective Date"). RECITALS WHEREAS, the OCHD is a local governmental entity devoted to improving the health of the citizens of Orange County,North Carolina(the"Conn "); WHEREAS,PPSAT presently maintains and operates a health care clinic located in Chapel Hill, North Carolina (the "Facili ") at which PPSAT and its licensed professionals provide vasectomies and related patient counseling services(the"Subject Services")to County residents; WHEREAS, OCHD desires to engage PPSAT, and PPSAT desires to provide to OCHD, the Subject Services for eligible men pursuant to the terms of this Agreement. NOW, THEREFORE, in consideration of the terms, conditions, covenants, agreements and obligations herein stated,it is mutually agreed by and between the parties as follows: 1. Duties of PPSAT. 1.1 Provision of Medical Staff. During the term of this Agreement, PPSAT shall provide licensed physicians and such physician extenders (Nurse Practitioner(s) or Physician Assistant(s)) (hereafter collectively referred as "Medical Professionals"), and/or nurses and/or medical assistants ("Medical Assistants") as may be necessary to provide the Subject Services at the Facility to patients. PPSAT shall ensure that its Medical Professionals and Medical Assistants perform the Subject Services in a manner consistent with the standards of professional ethics and practice and in accordance with all requirements of applicable professional associations and all local, state and federal laws. 1.2 Provision of Space. At all times during the existence of this Agreement, PPSAT shall, at its own cost, operate and maintain the Facility in conformity with all applicable federal, state and local laws, rules and regulations, including pertinent licensure requirements. PPSAT shall obtain or cause to be obtained and shall maintain or cause to be maintained, at PPSAT's sole expense, any and all licenses or permits required in connection with the operation of the Facility including, without limitation, the performance of all Subject Services required under this Agreement. 1.3 Provision of Equipment and Supplies. PPSAT shall, at its own cost, be responsible for and shall make available or cause to be made available all equipment, supplies (including, without limitation, all anesthetics or other drugs), trained personnel, and support services reasonably required needed to enable, allow and permit PPSAT to perform the Subject Services at the Facility and discharge its duties under this Agreement in conformity with all applicable and reasonable standards of care. 30843134 v3 DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 1.4 Scheduling of patients. PPSAT shall be responsible for scheduling all patients requiring the Subject Services at the Facility consistent with the customary operating schedule of the Facility. 1.5 Medical Records. PPSAT shall maintain medical records with respect to all of the patients in a professional manner consistent with the accepted practice of the community and in accordance with federal and state confidentiality laws. 1.6 No Discrimination. PPSAT shall not refuse to treat a patient on the basis of the patient's race, color,national origin, disability, gender,religion, or age. 2. Duties of OCHD. 2.1 Patient Eli ibg ili ty. OCHD shall be solely responsible for ensuring that patients meet the eligibility criteria. 2.2 Program Compliance. OCHD shall be solely responsible for completing and filing any applications and complying with any laws or regulations as necessary to allow it to bill and/or collect funds for the Subject Services performed under this Agreement. 3. Relationship of Parties. None of the provisions of this Agreement are intended to create, and none shall be deemed or construed to create, any relationship between OCHD and PPSAT other than that of independent entities contracting with each other solely for the purpose of effecting the provisions of this Agreement. Neither the parties hereto nor any of their respective employees or agents shall be construed under this Agreement to be the partner, joint venturer, agent, employer, or representative of, or investor in,the other. 4. Compensation and Billing Requirements. 4.1 Compensation. In exchange for Subject Services performed by PPSAT pursuant to this Agreement, OCHD shall pay to PPSAT the amount specified in Exhibit A, attached hereto and incorporated herein by reference, subject to adjustment at the beginning of each fiscal year. The maximum amount payable for Subject Services under this Agreement shall not exceed five thousand forty dollars($5040.00). 4.2 Financial Responsibility. OCHD shall act as the exclusive payor for Subject Services provided under this Agreement. PPSAT shall only look to OCHD for payment for the Subject Services performed under this Agreement, and not to the patient. 4.3 Billing and Payment Procedures. (a) Payment. Within 30 days of the Effective Date, OCHD shall deposit the amount of$5,040.00 with PPSAT as payment for the Subject Services to be performed under this Agreement. (b) Invoices. On a monthly basis, by the 10' day of each month, PPSAT shall present to OCHD an invoice indicating the number of Subject Services performed in the prior month and the corresponding fees. The obligation to present monthly invoices terminates when the funds provided by OCHD are exhausted. Any unused funds will be refunded to OCHD. 30843134 v3 2 DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 4.4 Compliance with Laws. OCHD and PPSAT have entered into this Agreement with the intent of conducting their professional services relationship in full compliance with applicable state, local, and federal laws including, but not limited to, the Medicare/Medicaid Anti-Fraud and Abuse and Stark laws. Accordingly, the compensation payable to PPSAT has been negotiated in good faith and in arm's-length negotiations and represents the fair market value of the services provided by PPSAT under this Agreement, taking into consideration the fair market value of all services provided hereunder. By executing this Agreement PPSAT affirms that PPSAT and any subcontractors of PPSAT are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement PPSAT certifies that PPSAT 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 PPSAT certifies that PPSAT 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. 5. Representations and Warranties of PPSAT. PPSAT represents and warrants to OCHD, upon execution and throughout the term of this Agreement, as follows: 5.1 PPSAT is not bound by any agreement or arrangement which would preclude it from entering into, or from fully performing the services required under,this Agreement; 5.2 Each of the Medical Professionals is licensed to practice medicine in the State of North Carolina and maintains all appropriate licenses, permits and certifications necessary to render the Subject Services pursuant to this Agreement; 5.3 All Subject Services provided by PPSAT hereunder shall be performed by PPSAT in accordance with all applicable federal, state, and local laws, rules and regulations, as well as any accreditation agency standards applicable to PPSAT; 5.4 Neither PPSAT nor any of its staff have been and are not currently suspended, excluded, barred or sanctioned by the Medicare or Medicaid programs or other federal or state programs (as defined at 42 U.S.C. § 1320a-7b(f)). 6. Representations and Warranties of OCHD. OCHD represents and warrants to PPSAT, upon execution and throughout the term of this Agreement,as follows: 6.1 OCHD is not bound by any agreement or arrangement which would preclude it from entering into, or from fully performing the services required under,this Agreement; 6.2 OCHD maintains all approvals necessary to providing funding for the Subject Services. 7. Term and Termination. 7.1 Term. This Agreement shall become effective as of the Effective Date, and shall remain in full force and effect for a period of one (1) year, unless the parties otherwise agree in writing to an earlier termination of this Agreement or this Agreement is earlier terminated as provided herein. Thereafter, this Agreement may be renewed annually for successive 30843134 0 3 DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 one (1) year periods, unless the parties otherwise agree in writing to an earlier termination of this Agreement or this Agreement is earlier terminated as provided herein. 7.2 Termination Without Cause. Either party can terminate this Agreement without cause at any time upon sixty(60)days prior written notice to the other party. 7.3 Termination With Cause. Either party may terminate this Agreement by notice in writing to the other party if the other party materially breaches this Agreement in any manner and such material breach continues for a period of twenty (20) days after written notice is given to the breaching party by the other party specifying the nature of the breach and requesting that it be cured. 8. PPSAT Insurance Requirements. PPSAT shall maintain in full force and effect during the term of this Agreement professional liability insurance covering PPSAT, its employees and agents ("insureds") against all claims arising out of or related to the performance of services by such insureds in connection with this Agreement. Such insurance shall be in coverage amounts of not less than $2 million per incident and $5 million annual aggregate. PPSAT also shall have and shall maintain throughout the term of this Agreement, hazard and general commercial liability insurance for its premises, in such amounts as deemed appropriate by PPSAT. PPSAT also shall have Workers' Comprehensive insurance as required by North Carolina State law. Certificates of insurance shall be given to Orange County upon request. 9. Ownership of and Access to Patient Records. All patient records, case histories and other information prepared or generated by PPSAT pursuant to this Agreement shall belong to and remain the property of PPSAT. PPSAT shall adopt and implement procedures which shall seek to assure maximum confidentiality of all patient records prepared pursuant to this Agreement and shall comply with all applicable federal, state and local laws and regulations relating to the privacy and security of such records, including all applicable sections of the Health Insurance Portability and Accountability Act of 1996 and the Health Information Technology for Economic and Clinical Health Act, including corresponding regulations. Access to any medical record of a patient shall be controlled by applicable federal, state and local laws and this Agreement. 10. Assignability. This Agreement shall not be assignable by either party. 11. Resolution of Disputes. The parties shall attempt in good faith to resolve any dispute arising out of or in any way connected with this Agreement and/or the relationship which arises hereunder by negotiations between representatives of the parties who have authority to settle the controversy. The parties agree that any dispute arising out of this Agreement which has not been resolved informally shall be brought exclusively in the state or federal courts with jurisdiction over Chapel Hill,North Carolina,and the parties hereby consent to such jurisdiction. 12. Waiver of Breach. The waiver of either party of a breach or violation of any provision of the Agreement shall not operate as, or be construed to be, a waiver of any subsequent breach of the same or other provision hereof. 13. Entire Agreement and Signatures. This Agreement constitutes the entire agreement between the parties and supersedes any other agreements between the parties relating to the subject matter herein. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent of the Parties to utilize electronic signatures and the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. 30843134 v3 4 DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 14. Notices. Unless otherwise set forth herein, all notices, requests, demands and other communications hereunder shall be in writing and shall be delivered by hand, reputable overnight delivery service or mailed by registered or certified mail, return receipt requested, first class postage prepaid,addressed as follows: If to PPSAT: Nancy M. Long Chief Financial Officer Planned Parenthood South Atlantic 100 S. Boylan Avenue Raleigh,NC 27603 If to OCHD: Pam McCall Personal Health Services Director 300 W. Tryon Street Hillsborough,NC 27278 15. Applicable Law. This Agreement will be controlled, construed and enforced in accordance with the laws of the State of North Carolina. 16. Severability. If any provision or part of this Agreement is found to be totally or partially invalid, illegal or unenforceable, then the provision will be deemed to be modified or restricted to the extent and in the manner necessary to make it valid, legal or enforceable, or it will be excised from this Agreement without affecting any other provision of this Agreement. 17. Amendments. This Agreement may be amended, changed, or modified only by written agreement executed and signed by the parties hereto. 18. Binding on Successors and Assigns. The terms, covenants, conditions,provisions and agreements herein contained shall be binding upon and inure to the benefit of the parties hereto and their successors. 19. Counterparts. This Agreement may be executed in any number of counterparts each of which shall be an original and all of such counterparts shall all together constitute but one and the same Agreement. IN WITNESS WHEREOF, the Parties, by and through their duly authorized officers, have caused this Agreement to be made effective as of the Effective Date. Planned Parenthood South Atlantic,Inc. DocuSigned by: A-. th" By BS168G970F20465... Its: Chief Financial Officer 30843134 v3 5 DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 Orange County,North Carolina By:1DocuSigned by: 6'379946755E477.. Its: County Manager 30843134 v3 6 DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 EXHIBIT A FEE SCHEDULE FOR PROMPT PAY FOR FISCAL YEAR 2017-2018 Level 1,New(OV/Consult) $50 Specimen Handling $10 Vasectomy, Semen Analysis $550 Postvasectomy $20 Total $630 30843134 0 7 DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 �T a DATE(MM/DDIYYYY) ��. CERTIFICATE OF LIABILITY INSURANCE 09/06/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Marsh USA,Inc. NAME: PHONE FAX 1166 Avenue of the Americas A/C No Ext: A/C No), New York,NY 10036 E-MAIL Attn:healthcare.accountscss @marsh.com Fax:212-948-1307 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN1 01357758-NIP-CAS-1 8-19 ROA,V GLUM INSURER A:New Hampshire Insurance Company 23841 INSURED INSURER 13:N/A N/A PLANNED PARENTHOOD SOUTH ATLANTIC AN AFFILIATE OF PLANNED PARENTHOOD INSURER C, FEDERATION OF AMERICA,INC. INSURER D: 2207 PETERS CREEK ROAD ROANOKE,VA 24017 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-010345501-01 REVISION NUMBER: 3 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 POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICYNUMBER MM/DD/YYYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY 082695195 01/01/2018 01/01/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE CLAIMS-MADE � OCCUR PREM REMISES(Ea a occur',nte $ 500,000 X SIR:$100,000 MED EXP(Any one person) $ Included PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑ PRO- POLICY [X] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X UMBRELLALIAB X OCCUR 086396874 01/01/2018 01/01/2019 EACH OCCURRENCE $ 3,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below ___,E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:CLINICIANS WITH OCHS WILL BE PERFORMING VASECTOMIES AT OUR SITES AS PER CONTRACT. ORANGE COUNTY HEALTH DEPARTMENT IS INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT WITH RESPECTS TO GENERAL LIABILITY. CERTIFICATE HOLDER CANCELLATION ORANGE COUNTY HEALTH DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN:PAM MCCALL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 300 W TRYON STREET ACCORDANCE WITH THE POLICY PROVISIONS. HILLSBOROUGH,VA 27278 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Ricki Fitzsimmons ',_ ,. - .—_. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 �T a DATE(MM/DDIYYYY) ��. CERTIFICATE OF LIABILITY INSURANCE 10/04/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Marsh USA,Inc. NAME: PHONE FAX 1166 Avenue of the Americas A/C No Ext: A/C No), New York,NY 10036 E-MAIL Attn:healthcare.accountscss @marsh.com Fax:212-948-1307 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN101357758-PL ON-PROVI-18-19 RAL,NC PL INSURER A:National Union Fire Ins.Co.of Pittsburgh,PA 19445 INSURED INSURER B: PLANNED PARENTHOOD SOUTH ATLANTIC AN AFFILIATE OF PLANNED INSURER C, PARENTHOOD FEDERATION OF AMERICA,INC. INSURER D, 100 S.BOYLAN AVENUE RALEIGH,NC 27603 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-010361938-02 REVISION NUMBER: 2 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 POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICYNUMBER MM/DD/YYYY MM/DDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 1:1 OCCUR DAMAGE ( RENTED PREMISES S Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- JECT ❑ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER I OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A MEDICAL PROFESSIONAL 6793286 01/01/2018 01/01/2019 EACH WRONGFUL ACT $1,000,000 CLAIMS-MADE COVERAGE 'Program Retro Date:11/1/76' AGGREGATE $3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:COVERAGE FOR ALL PPSAT CLINICIANS CERTIFICATE HOLDER CANCELLATION PLANNED PARENTHOOD SOUTH ATLANTIC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 100 S BOYLAN AVENUE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RALEIGH,NC 27603 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Ricki Fitzsimmons ',_ ,. - .—_. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:32C22978-D1B8-4515-AD1A-21853E88FAA8 r r • r r NEW HAMPSHIRE INSURANCE COMPANY 0008042-00 WC 015-42-5152 13080 __..____..____..-------------------------------- 055-02-0118-10 •• • • PENN YLVAN! •• A PLANNED PARENTHOOD SOUTH ATLANTIC I G 100 SOUTH BOYLAN AVE RALEIGH, NC 27603-0000 An AIG company EXECUTIVE OFFICES; SEE EXTENSION OF ITEM-1. OF THE INFORMATION PAGE - WC990610 175 Water Street New York, NY 10038 LD# 911810018 PRODUCERS NAME AND ADDRESS MARSH USA INC. WORKERS COMPENSATION AND EMPLOYERS 1166 AVENUE OF THE AMERICAS LIABILITY POLICY INFORMATION PAGE NEW YORK, NY 10036-3712 INSURED IS PREVIOUS POLICY NUMBER CORPORATION RENEWAL 015425152 OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1, OF THE INFORMATION PAGE - WC990610 ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insured's mailing address FROM 01 /01 /18 TO 01/01/19 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: NC SC VA WV B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1 ,000,000 each accident Bodily injury by Disease $ 1 .000.000 policy limit Bodily Injury by Disease $ 1 .000.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AL AR AZ CA CO CT DC DE FL GA HI .IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NH NJ NM NV NY OK OR PA RI SD TN TX UT VT WI D. This policy includes these endorsements and schedules: SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 ITEM 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. Premium Basis Rate Per Estimated classifloatlons Code Number Total Remuneration S100 OF Re- Premium N Annual El 3 Year mimeration Annual ❑3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $30 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $26o VA MINIMUM PREMIUM $750 NC TOTAL ESTIMATED ANNUAL PREMIUM $31 ,o74 If indicated below, interim adjustments of premium shall be made: ❑ Semi-Annually ❑ Quarterly ❑ Monthly DEPOSIT PREMIUM $31 ,074 0110211$ CHICAGO 02 � Issue Date Issuing Office Authorized Representative WC 00 00 01A 39967(Rev'd 04108)