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HomeMy WebLinkAbout2021-492-Health-UNC Healthcare System-Perform tubal ligations for uninsured womenDocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723 DocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723 DocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723 DocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723 DocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723 DocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723 DocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723 DocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723 Revised 06/21 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: UNC Healthcare System Party/Vendor Contact Person: Kathryn Grant Contact Phone: 984- 974-1274 Party/Vendor Address: 5221 Paramount Parkway, Suite 420 City Morrisville State: NC Zip: 27560 Department: Health Amount: $10,000 Purpose: Perform tubal ligations for uninsured women Budget Code(s): 10414020-631010-71401 Vendor # 21680 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 8-25-21 Approved by Board Yes No Agenda Date: --- For Section XIV. c. contracts only, Approved by Board in Current FY Budget Yes No This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: Department Director’s Signature ________________________________________ Date: ________ Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: Information Technologies (Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723 9/7/2021 9/9/2021 9/13/2021 9/13/2021 CERTIFICATE OF COVERAGE Certificate Holder: Alexandria Real Estate Equities, Inc. C/O Business Credentialing Services PO Box 1258 Morristown, NJ 07960 Insurer: State of North Carolina Authorization: Public Officers & Employee Liability Insurance Commission of North Carolina and the General Statutes of North Carolina, Chapter 143, Articles 31 to 31D, Sections §143-291 to §143-300. Period: February 01, 2021 until February 01, 2022 Coverage: A) Tort Claims against Departments, Agencies, and Employees B) Excess Liability for State Employees BRIT Global Specialty USA - Policy # PK1035819; Kinsale Insurance Company – Policy #0100154765-0 Limits A) $1,000,000 for Tort claims against the State B) $2,000,000 per employee/$10,000,000 aggregate for claims against state employees. Description: University of North Carolina Chapel Hill and its employees, officers, agents, as covered by the Defense of State Employees as per NCGS § 143 300.2. Administrator: Department Insurance - Risk Management Division Public Officers & Employees Liability Insurance Commission 1202 Mail Service Center, Raleigh, NC 27699-1202 Note: This Certificate is for informational purposes only and does not alter any provision of the Tort Claims or Defense of State Employees General Statutes of the State. Verified By: Bryan Heckle, CIC, CPCU, CRM Deputy Commissioner of Risk Management UNC-CH DocuSign Envelope ID: FB7430B2-2FBF-411A-80CE-DED9CB34C723