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HomeMy WebLinkAbout2016-754-E Finance - A Helping Hand performance agreement DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2016, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough,North Carolina,27278, ("County") and A Helping Hand, a not-for-profit corporation, located at 1502 W. NC Hwy 54, Suite 405,Durham,NC 27707 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need,as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth,the County and A Helping Hand agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2016 to June 30, 2017. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 5000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $1,250. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (A Helping Hand) Orange County Outside Agency Performance Agreement Revised 812016 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 -June 30. Reports are due on January 13,April 14, and July 14 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance,incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider,the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (A Helping Hand) Orange County Outside Agency Performance Agreement Rev. 8116 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers'or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury,including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance,including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents,consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A-Statutory State NC&Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (A Helping Hand) Orange County Outside Agency Performance Agreement Rev. 8116 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider 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 the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee,no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.15 per hour. To the extent possible, Orange County recommends that A Helping Hand provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (A Helping Hand) Orange County Outside Agency Performance Agreement Rev. 8116 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC County: Finance&Administrative Services Provider: A Helping Hand Orange County 1502 W.NC Hwy 54, Suite 405 Post Office Box 8181 Durham,NC 27707 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part,term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. 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. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. Docu5igned by: For an �C ,r aS eider CiE40BbDAD5346D.._ 10/26/2016 Date For an[Docu signed by: _ - - unty Government 6GLIn.�t. �"Gu�wtt.Y'S� 10/31/2016 0637994B755E477... Bonnie Hammersley, County Manager Date (A Helping Hand) Orange County Outside Agency Performance Agreement Rev. 8116 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC ATTACHMENT "A" Orange County Certifications—FY 2016-17 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name,title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. OocuSigned by: aS Executive Director 10/26/2016 34 Certified y Uy: C1E40BaDA�5B Title: Date' (Provider's Signature) (A Helping Hand) Orange County Outside Agency Performance Agreement Rev. 8116 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC _Xhlblt A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency A Helping Hand Date/Time Complete Y 1 N Program(s) Senior Companion Care Section Subsection For D' i Regulations 1. Cover Page a. 2 Applicant Contact Information b. Z Project/Program Contact Information c. Funding Requests Identified d. Signed Application Cover Page 2. Agency a. ® Agency's Years in operation 24 CFR 570.506, Information - b. ® Agency's Purpose/Mission 570.507, 570.610; 24 c. Agency's Types of Services Provided CFR Parts 84 or 85 d. ® Agency's Experience e. Z Other Pertinent Information 3. Program/ a. ® Type of Application and Program Identified 24 CFR 570.200(a), Project b. N Summary of Program 570,201-570. 208, Information - 507.503 c. ® +Description of Identified Need [for each d. E Description of Population to be Served program/ I project for e. [Z Activity Manager and Location Description which funding f. Z Activity Implementation Timeline is requested} g• Z Agency Collaboration h. Z Describe Impact of Reduced/No Allocation i. M Other Pertinent Information j. Z Complete Target PopulafionlBeneficiary Chart k. ® Complete Schedule of Positions I. 17 Signed Conflict of Interest Disclosure m. Z Complete Work Statement i Page DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 206, each expenses for the entire program and ALL sources of 507,503 program/ funding, 24 CFR 570.506, project for 570.507, 570.601, which funding a. ® Program Budget Worksheet 570.602, 570.607(b), is requested) b. ® Program Budget Detail 570.611 c. Cost Per Unit 24 CFR d. Agency Operating Budget Worksheet 570,502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A 122; Treasury Circular 1075 5. Supplemental A. Part A: CDBG $ HOME Sections (as B. ® Part B: Cons tructionlRehab applicable) 6. Attachments a. ® Audit. Organizations receiving $300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. IRS Federal Form 990 c. NC Solicitation License d. IRS Federal Tax-Exemption Letter e. Certificate of Insurance f. List of Board of Directors 24 CFR Parts 84 or 85 g. ® Articles of Incorporation/Bylaws 24 CFR 570.208, h. Z Authorization to Request Funds 570.500(c), 570.611 i. Z Authorized official designation j. E Solid Waste Program Fee (SWPF) Verification Main Application 1/25/201 6 1:23:46 PM P �1 , c, 2 n f 2 6 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.} a) Apelicant Contact Information Applicant Organization's Legal Name: A Helping Hand Applicant Organization's Physical Address: 1502 West NC Highway 54 Suite 405 Durham NC 27707 Applicant Organization's Mailing Address: 1502 West NC Highway 54 Suite 405 Durham INC 27707 Applicant Organization's Web Address: www.ahelpinghandnc.org Executive Director: Jennifer Ashley Telephone Number: 919-403-5555 E-Mail: jennifer,ashle ahel in handnc.or DUDS Number: (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Pro ect/Proctram Contact Information Project/Program Name: Senior Companion Care Program Project/Program Primary Contact and Title: Jennifer Ashley. Executive Director Telephone Number: 919-403-5555 E-Mail: Jennifer.ashleyOahelping hand nc.gM c) Funding Request Identification Total Project/Program Cost: $ Total Amount of Funds Requested: $ 16,000 Proposed Use of Funds Requested (2-3 Line Maximum): Provide non-medical independent living services for senior citizens and adults with disabilities, regardless of their ability to pay. Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints. ❑ CDBG Non-Construction (CH) $ ❑ Grant ❑ Loan ❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan ❑ HOME CHDO (OC) $ ❑ Grant ❑ Loan ❑ HOME Other (OC) $ ❑ Grant ❑ Loan F� Human Services: Carrboro $4,000 ® Chapel Hill $4,000 ® Orange County $8,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: + f E� t i v Dir ctor Date Main Application 1/25/201 6 1:23:46 PM Page 3 of 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application _ MAIN APPLICATION Signature: Board Chairperson Date Main Application 1/25/201+6 1:23:46 PM P a g e 4 of 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month[Year) A Helping Hand has been in operation for 20 years. We were incorporated in June of 1995. b) Agency's Purpose/Mission A Helping Hand (AHH)improves quality of life, decreases health disparities,and reduces barriers to human services by providing independent living assistance to senior citizens (60+) and disabled individuals (18+), regardless of an individual's ability to pay. Cathy Ahrendsen founded A Helping Hand (AHH) in 1995 in response to an unmet community need for high caliber senior support services. We are honored to have grown from serving 21 individuals in 1995 to now providing support to nearly 420 individuals annually. A Helping Hand's success remains rooted in our vision of excellence for all people. Many seniors are unable to pay market rates for services; however, by utilizing volunteers and grant funding A Helping Hand is able to provide vital assistance to people of all income levels. c) Types of Services the Agency Provides AHH offers an innovative response to age-related limitations by providing a person-centered approach to care that meets the varying needs of seniors. AHH provides companionship services, in-home assistance, door-through-door transportation, and respite care. Services enhance quality of life, promote self-sufficiency, and prevent premature transitions to higher levels of care. Assistance affords individuals the opportunity to remain active and to safely"age in place." Key needs addressed by A Helping Hand include: a) Improving accessibility to health care; b) mental stimulation and socialization; c) promoting exercise and mobility; d) encouraging proper nutrition; e) maintaining a safe home environment; f) respite for caregivers; and g) patient advocacy d) Agency's Experience with Similar Programs as the Funding Request A Helping Hand is the only nonprofit companion care agency in Orange and surrounding counties. We currently contract with Orange County Department on Aging in our provision of companion care services, as they do not fill this role in the community. We also strive to work closely with other senior services in order to create seamless transitions for our clients. e) Other Pertinent Agency Information Main Application 1/25/2016 1:23:46 PM P a g e 5 of 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECTIPROGRAM INFORMATION Agency & Program Name: A Hering Hand 1 Senior Companion Care a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: Z Human Services (Main Application~ Only) ❑ CDBG Non-Construction —(Main Application AND Part A) Q CDBG Construction — (Main Application AND Part A AND Part B) ❑ HOME CHDO Set-aside —(Main Application AND Part A) ❑ HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Disabled Public Housing Program Category Youth Adult Elderly (not elderly) Neighborhoods/Residents Education Health and Nutrition X Jab Training Sports and Arts Activities Pre-School Activities After-School Activities Mentorin Transportation X Housing Other: Please specify Pro9raL13JPro81F,1 D i (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? Provide non-medical independent living services for senior citizens and adults with disabilities, regardless of their ability to pay. Services include escorted "door-through-door" transportation, in-home assistance including light housekeeping and meal preparation, companionship, and respite care. c) Describe the local need or problem to be addressed in relation to the Consolidated Plan or other community priorities (i.e. Council/Board Goals). Cite local data to support the need far this program and the population being served. Main Application 1/25/2016 1:23:46 PM P c1 g e 7 of 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION] As the population of seniors (65+) increases exponentially, an expansion of services is required to meet the special needs of this at-risk demographic. In 2013, one in 5 North Carolina residents were 60 and over in the state. In 2033, one in four will be over 60 and over. According to the US Census Bureau, there are approximately 13,962 individuals aged 65+ in Orange County; nearly 10% of these individuals are living at or below poverty level and are unable to afford independent living services. This augmented population of seniors is resulting in an increased demand for services on an already heavily burdened human services system. In order to reduce the public cost of caring for these individuals, it is necessary to provide services that allow a person to "age in place" with minimal barriers to service. A Helping Hand (AHH) is the only non-profit in Orange County that provides in-home assistance regardless of an individual's ability to pay. Transportation is frequently identified as the number one unmet need for seniors. In fact, the latest Orange County Health Assessment identified the lack of transportation services as a primary barrier to healthcare access. Fortunately, AHH is able to increase access to healthcare and other valuable services by filling gaps in current transportation models. As current community transportation exists, assistance is limited to"door-to-door"and is subject to geographical and scheduling restrictions. AHH's escorted "door-through-door" transportation is critical to ensuring physically-disabled or cognitively-impaired seniors are able to travel safely to doctor's appointments and have access to other vital needs, regardless of time and location in the County. Moreover, the discrepancy between life expectancy and driving expectancy creates a pragmatic need for senior transportation services. On average, men and women experience respectively, seven and ten non-driving years. Ironically, as the ability to drive decreases, the frequency of medical appointments and the need for health services increases. The natural aging process often brings about physical and cognitive limitations that require assistance in the home. The DHHS Administration on Aging reports 37% of older people are limited by a disability. Moreover, in the future, the percentage of disabled individuals is also expected to grow. A report published in JAMA Internal Medicine, showed that the proportion of baby boomers who are disabled is substantially higher relative to people from two decades ago in the same age bracket.Without assistance,these individuals will experience premature transitions to higher, more expensive levels of care and are at increased risk for injury and illness. Providing independent living services will enable these individuals to maintain self- sufficient lives and will reduce the likelihood of injury from performing unmanageable household tasks. Social isolation among the elderly is a silent and often overlooked pandemic threatening the health and quality of life of our community's older adults. According to the American Community Survey, over 3,300 Orange County seniors over age 65 live alone. Many of these individuals are geographically isolated from their families and lack necessary support networks. A report in the Archives of Internal Medicine found 43% of older adults reported feelings of loneliness which can lead to depression, other negative psychological impacts, loss of physical functioning, and even premature death. Lonely adults in the study were 45% more likely to die than seniors who felt meaningful connections with others. AHH's companionship services provide an increased opportunity for socialization and mental Main Application 1/25/2016 1:23:46 PM P a g e 8 o f 2 6 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION stimulation. As reported in the Recommendations from the Governor's Advisory Council on Aging, failure to sustain, if not increase,. funding for senior services could have serious adverse effects on the well-being of the elderly and the public cost of caring for them. Funding from the Town of Chapel Hill, the Town of Carrboro and Orange County is essential to ensuring A Helping Hand is able to respond to the growing needs of Orange County senior citizens. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. See above related to population information. A Helping Hand, having been in operation for 20 years and with a reputation for high quality care and community involvement, solicits referrals from its community partners. These include Charles House, Orange County Department on Aging, Carolina Villages and many others. Our sliding scale fee model allows for us to meet any senior where they are in terms of financial need and provide services. e) Who specifically will carry out the activities and in what location will they be carried out? A Helping Hand provides services through a combination of paid companions, pre-health interns, and volunteers. We work in the community where there exists a need. A Helping Hand currently has the ability to serve seniors in the whole of Orange County. We assist individuals in their homes as well as in facilities and hospitals. f) Describe specifically the period over which the activities will be carried out, the frequency with which the activities will be carried out, and the frequency with which services will be delivered. Include an implementation timeline. A Helping Hand serves individuals in Orange county throughout the year on a 2417 basis. Frequency of services depends on client need and availability of staff members. As we are an existing service, there is no implementation timeline. These are the services that we provide. g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. Community collaborations and partnerships are instrumental to meeting the needs of our community's seniors. A Helping Hand is actively engaged in collaborative efforts to make Orange County the premier place to grow older and participates in a number of partnerships, committees and initiatives, including: • Orange County Department on Aging —AHH participates in meetings and sponsored initiatives by Orange County Dept. on Aging. This includes community information initiatives. In addition, we hold a contract with OCDOA to provide subsidized companion care for their clients. • Orange County Long-Term Care Learning Collaborative — AHH has participated in the Long-Term Care Learning Collaborative's projects, most recently receiving our certification in Music & Memory. Main Application 1/25/2016 1:23:46 PM P a g f:-�- 9 o f 2 6 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION • Chatham-Orange Community Resource Connections for Aging and Disabilities Committee —AHH is a member of this group and participates in its initiatives. AHH regularly refers clients to, and receives referrals from: • The Orange County Department on Aging • Carolina Villages, Charles House • Orange County Health Department UNC Hospitals • Veteran's Administration • Meals on Wheels • Local physicians, social workers, and clinics h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. A Helping Hand is committed to its mission and will continue to provide services regardless of funding fluctuations. A reduced allocation will impact the number of seniors in the area that we are able to serve. We will also work to raise funds from other sources. i) Include any other pertinent information. ProgramlProiect Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule- of Positions Chart for Program Staff 1) Disclosure of Potential Conflicts of Interested must be signed m) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Information to Complete j.) Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: ❑ Persons ❑ Households ❑ Units Program: Senior Companion Care Program Beneficiary Demo raphics Actual Estimated Projected 2014-15 2015-16 201E-17 Gender Male 51 60 65 Female 180 200 205 Total F 231 260 270 Main Application 1/25/2016 1:23:46 PM Page 1 0 o f 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION Of the females, how many are single- female Head of Households(Omit for Human Services) Ethnicity African-American 35 40 45 American Indian or Alaska Native 0 0 0 Asian 3 3 5 Caucasian 190 214 215 Native Hawaiian or other Pacific Islander 0 0 0 Other 3 3 5 Totall 23 1 260 270 Of the above, how many Hispanic/Latino 0 0 0 Of the above, how many non- Hispanic/Latino Total 231 260 270 Age 0-5 years 6-18 years 19-50 years 12 20 10 51-61 years 67 57 60 62+years 152 183 200 Total 231 260 270 Geographic Location Durham City 83 90 90 Durham County 0 0 0 Carrboro 34 60 65 Chapel Hill 97 89 90 Chapel Hill Public Housing Residents ? ? ? Orange County 12 18 20 Raleigh 0 0 0 Wake County 5 3 5 'fatal 231 260 270 Income Level—See following chart (Omit for HS) < 30%Area Median Income 200 230 240 31-50%Area Median Income 31 30 30 51-80%Area Median Income >80%Area Median Income Total 231 260 270 Special beads(Omit for HS) Elderly(Over 62) Disabled(not elderly) Homeless Main Application 1/25/201 6 1:23:46 PM Page 11 of 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION People with HIV/Aids Total 0 1a Main Application 1/25/2016 1:23:46 PM P a g e 1 2 a F 2 6 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). If provided, indicate: Position Titles %FTE* Actual Estimated Projected %Total Retirement Vaacan -Vacant # Program Staff+ram 2014-15 2015-16 201.6-17 Budget Plan (H) Health Plan Executive Director 1.00 90(1) 38,065 55,000 55,000 9% N/A 10(2) Program Director 1.00 90(1) 37,548 38,065 38,065 6% N/A 10(2) Finance Director 1.00 90(1) 30,239 36,500 36,500 6% N/A 10(2) Client Services .875 90(1) 23,705 28,510 28,510 5% N/A Director 10(2) Program Assistant 1.00 100(1) 38,052 29,110 29,110 5% N/A Companions 12 100(1) 221,154 235,000 240,000 42% N/A Volunteers 2.24 100(1) 0 0 0 0% N/A Field Supervisor 1.00 100(1) 0 27,040 27,040 4% N/A Notes: + Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • .. Full Time Equivalent staff will be noted as 1.00; half time as .50;quarter time as .25, etc. + Denotes the percentage of staff time involved with this program. Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours=Volunteer FTE 1,960 Main Application 1/25/2016 1:23:4+6 PM p a g e 1 4 o f 2 6 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO ❑ Z a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? ❑ Z b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? ❑ ® c) Current beneficiaries of the project/program for which funds are requested? ❑ Z d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered 'YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: E e uti i recto r Dat Signature: Carat Board Chairperson Date Main Application 1/25/2016 1:23:46 PM Page 1 6 o f 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application Actual Estimated Projected 2014-2015 2015-2016 2016-2017 Provide companionship,escorted Provide companionship,escorted Provide companionship,escorted "door-through-doors" "'door-through-door'" ""door-through-door" Program transportation,in-home transportation,in-home transportation,in-home Activity 1 assistance including light assistance including light assistance including light housekeeping and meal housekeeping and meat housekeeping and meal preparation,and respite care preparation,and respite care preparation,and respite care A minimum of 30 orange County A minimum of 50 Orange County A minimum of 50 orange County Program Goal residents will receive subsidized residents will receive subsidized residents will receive subsidized assistance assistance assistance Performance Regular recording and tracking of Regular recording and tracking of Regular recording and tracking of Measures service delivery. service delivery. service delivery. Requested funding allowed AHH Requested funding will allowAHH 'Requested funding allowed AHH to provide 38 orange County to provide 50 Orange County to provide Gil Orange County Program residents with services that help residents with services that help residents with services that help Results individuals maintain quality of life individuals maintain quality of life individuals maintain quality of life and independence;increase and independence;increase and independence;increase access to health and human access to health and human access to health and human services;reduce social isolation; services;reduce social isolation; services;reduce social isolation; and,promote physical and mental and,promote physical and mental and,promote physical and mental wellbeing. wellbeing. wellbeing. Provide companionship,escorted Provide companionship,escorted Provide companionship,escorted "door-through-door"' "door-through-door" ""door-through-door'" Program transportation,in-home transportation,in-home transportation,in-home Activity 2 assistance including light assistance including light assistance including light housekeeping and meal housekeeping and meal housekeeping and meal preparation,and respite care. preparation,and respite care. preparation,and respite care. A minimum of 550 hours o A minimum of 850 hours of A minimum of 950 hours o subsidized assistance will be subsidized assistance will be subsidized assistance will be Program Goal provided to orange County provided to orange County provided to orange County residents. residents. residents. Performance Regular recording and tracking of Regular recording and tracking of Regular recording and tracking of Measures service delivery. service delivery. service delivery. Requested funding allowed AHH Requested funding will allow AHH Requested funding will allow AHH to provide 830 hours of service to provide 850 hours of service to provide 950 hours of service to orange County residents with to Orange County residents with to{range County residents with Program services that help individuals services that help individuals services that help individuals Results maintain quality of life and maintain quality of life and maintain quality of life and independence;.increase access to independence;increase access to independence;increase access to health and human services; health and human services; health and human services;. reduce social isolation;and, reduce social isolation;and, reduce social isolation;and, promote physical and mental promote physical and mental promote physical and mental wellbeing. wellbeing. 1wellbeing. DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application Provide companionship,escorted Provide companionship,escorted Provide companionship,escorted "door-through-door" "door-through-door" "cloor-through-door" transportation,in-home transportation,in-home transportation,in-home assistance including light assistance including light assistance including light Program housekeeping and meal housekeeping and meal housekeeping and meal Activity 3 preparation,and respite care. preparation,and respite care. preparation,and respite care. 90%of program participants will 80'/of program participants will 80%of program participants will Program Goal remain in their homes or active in remain in their homes or active in remain in their homes or active in assisted living. assisted living. assisted living. Performance Regular recording and tracking of Regular recording and tracking of Regular recording and tracking of Measures service delivery. service delivery. service delivery. Provide companionship,escorted Provide companionship,escorted Provide companionship,escorted "door-through-door" "cloor-through-door" "door-through-door" transportation,in-home transportation,in-home transportation,in-home assistance including light assistance including light assistance including light Program housekeeping and meal housekeeping and meal housekeeping and meal Results preparation,and respite care. preparation,and respite care. preparation,and respite care. Program Activity 4 Program Goal Performanceii Measures Program Results Program Activity 5 Program Goal Performance Measures Program Results DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION Program Budget AgencytProgram, A Helping Hand/Senior Companion Care Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 38,711 $ 40,600 $ 45,000 11% Agency Generated Revenue(fees) *$ 3, $ - $ - *0% Local Government Grants: Orange County 0 $ 3, 000 $ 3,100 Town of Chapel Hill $ 4,000 $ 4,0001 $ 4,000 0% Town of Carrboro $ 2,000 $ 2,000 1 $ 2,000 0% Other Local•. Durham County $ 12,000 $ 12.000 1 $ 12,000 0%® Other Local: 1 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle united Way $ 160 $ 160 $ 160 0°l0 State Government 0 Federal Government 0' Other Grants: 0' Other Grants: 0 MiscellaneoustOther Revenue $ 22,000 $ 24,000 $ 30,000 25% Please list 3 largest Miscellanous sources: Mary Goddard Pickens $ 12,000.00 Faile Foundation $ 10,000M Total Agency Revenue S 81 971 85 860 96 260 12%' AGENCY EXPENSES Compensation $ 52,371 $ 56,260 $ 66,660 18% Rent&Utilities $ 8,000 $ 8,000 $ 8,000 0% Supplies&Equipment $ 1,200 $ 1,200 $ 1,200 0% Travel&Training $ 400 $ 400 $ 400 0% Other Expenses: $ 20,000 $ 20,000 $ 20,000 0% Please list 3 largest"Other Expenses": Insurance $ 15,000.00 Mileage Reimbursement $ 3,000.00 Payroll Taxes $ 2,000.00 Total Agency Expenses 81 9771 $ 85 860 96,2601 12%m SURPLUS1(DEFICIT)FOR PERIOD: $ - 1 $ - if - 1 0 Main Application 1/25/2016 1:23:46 PM Page 22 of 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost Quantity/Unit of Measure Subtotal($) Credit Counseling Teacher--in class $25 96 hours(8 hrslmth x 12 months) $2,400 Credit Counseling Teacher—class,prep $25 48 hours(4hrslmth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours(10 hrsl'mth x12 mths $2,400 Materials $25 120yw�course packets/credit reports $3,000 Total $9,000 Complete the table below for the ro'ectl ro ram for which you are requesting funds. Attach additional rows/pages, as needed. Program: Senior Companion Care Cost Elements Cast $ Quanti lllnit of measure Subtotal Partial Salary For Program Assistant $14,555 50%of role-scheduling,etc. $14,555 Advertising and recruitment of companions $500 Using both pay and free ads $500 Training of companions $165 Materials and staff time $165 Background checks $780 $26 perbackground check $780 Total 16,000 c.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program 523,365 535,260 551,260 Total # of Units 26,168 26,763 27,563 Cost Per unit 20.00 20.00 20.00 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 1/25/2016 1:23:46 PM Page 23 of 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency Budget Agency. A Helping Hared I Senior Companion Care Actual Estimated Protected 1 Percent AGENCY REVENUE 2014-15 2015.16 2016-17 Change Private Donations $ 38,GO0 $ 40,000 $ 45,000 13% Agency Generated Revenue(fees) *$ 442,105 $ 450,000 $ 455,000 1Local Government Grants:Change County 3,10D $ 3,100 $ 3,100 0°/0 Town of Chapel Hill $ 4.000 $ 4.000 $ 4,000 00/9 Town of Carrhoro $ 2,0001$ 2,000 $ 2,000 t7% Other Local: Durham County $ 12,000 1$ 12,000 $ 12,000 00/4 Other Local: 0 Other Local: ,p D le ase If more Iharr 3 sources provide a separate list. Non-Local Government Grants Triangle United Way $ 160 $ 160 $ 160 0% State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue $ 22,000 $ 24,00D $ 30A0a 25% Please list 3 largest bAscellanous sources: Mary Goddard Pickens $ 12,000M Faile Foundation $ 10,000.00 $ Total Agency Revenue 23365 535 260 551 260 3°% AGENCY EXPENSES Compensation $ 419,201 $ 429,202 $ 440202 3% Rent&Utilities $ 25„058 $ 25,058 $ 25,058 0% Supplies&Equipment $ 12,083 $ 12,000 $ 15.000 25% Travel&Training $ 883 $ 1,000 $ 1.000 0°k Other Expenses: $ 68,140 $ 68,000 $ 70.000 3°k Please list 3 largest-Cxher Expenses-: Insurance $ 20,000.00 Mileage Reimbursement $ 16.000.0a Payroll Taxes $ 37.195-00 Total Agency Expenses 52336.5 535.260 551 260 3% SURPLUSI(DEFICIT)FOR PERIOD: 5 - s - - a Main Application 1/25/2016 1:23:46 PM Page 25 of 26 DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC EXHIBIT"B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: A Helping Hand Funding Award: $5,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Provide non-medical independent living services for senior citizens and adults with disabilities 5,000 Regardless of their ability to pay Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • Provide companionship, escorted "door-through-door" transportation, in-home assistance including light houskeeping and meal preparation, and respite care Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Minimum of 50 Orange County Residents will receive subsidized assistance 50 people Mimmum of 950 hours of subsidized assistance will be provided to Orange County residents 950 hours 80%of porgram participants will remain in their homes or active in assisted living 80% DocuSigned by: asftif" Certified by: clEaaeaoaDg346D.- Title: Executive DirectorDate: 10/26/2016 (Provider's Signature) DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC OP ID: DS A� ' CERTIFICATE OF LIABILITY INSURANCE GATE o3117r2a1s1712016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Higgh&Rubish Insurance Agency NAME: P.O Box 3040 PHONEx AIC No Ext: LAIC 6015 Farrington Rd.Ste 101 S: Chapel Hill,NC 27517 ADDRES ADDRESEIi --- High&Rubish FRODCCUSTOMER ID R:HELPI-1 INSURER(S)AFFORDING COVERAGE NAIL V I.NSiJRED A Helping Hand 27707 INSURER A.Cincinnati Insurance Companies 10877 Durham, NC D urh am Hwy Ste 405 INSURER B..U.S.Liability Insurance Co. INSURER C INSURER D; INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRR TYPE OF INSURANCE IH&&WVD POLICY NUMBER MMIODIYYY _ (MMIDONYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A L. X COMMERCIAL GENERAL LIABILITY HHC0005W 0310112016 03/0112017 PREMISES Ea ccsurrence $ 100,000 CLAIMS-MADE FX_1 OCCUR MED EXP(Any one perm) $ 10,000 PERSONAL a ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENt AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 PIOLICYFI PRa LOC _ $ AUTOMOBILE uA61LrrY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per parson) $ ALL OWNED AUTOS BODILY INJURY(Per accitlenl) $ SCHEDULED AUTOS PROPERTY DAMAGE A �HIRED AUTOS HHC000588 03101/20/6 0310112017 (PER ACCIDENT) $ +X NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIA6 'CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- TH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS PER ANY PROPRIETORIPARTNERIEXECUTNE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NMI E.L.DISEASE-EA EMPLOYE $ If yes,deSer'be erMder ❑ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ B Professional Liab NDO10541771 '09/0912016 0910912D17 11000,000 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORD 101,AddltIonal Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION ORANIG-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Government ACCORDANCE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 South Cameron Street P.O. Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD