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HomeMy WebLinkAbout2023-431-E-Social Svc-Matala Psychological Services-psychological evaluations court testimonyRevised 04/23 1 [Departmental Use Only] TITLE Matala Psychological Services, PLLC FY 2023-24 NORTH CAROLINA SERVICES AGREEMENT NO RFP/RFQ ORANGE COUNTY This Services Agreement (hereinafter “Agreement”), made and entered into this 21st day of June, 2023, (“Effective Date”) by and between Orange County, North Carolina a political subdivision of the State of North Carolina (hereinafter, the "County") and Matala Psychological Services, PLLC, (hereinafter, the "Provider"). WITNESSETH: That the County and Provider, for the consideration herein named, do hereby agree as follows: 1. Services a. Scope of Work. i) This Agreement is for services to be rendered by Provider to County with respect to (insert type of project): psychological evaluations, parental competency evaluations, interpretive sessions, and/or court testimony ii) By executing this Agreement, the 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. iii) Time is of the essence with respect to this Agreement. iv) The services to be performed under this Agreement consist of Basic Services, as described and designated in Section 3 hereof. Compensation to the Provider for Basic Services under this Agreement shall be as set forth herein. 2. Responsibilities of the Provider a. Services to be provided. The Provider shall provide the County with all services required in Section 3 to satisfactorily complete the Project within the time limitations set forth herein and in accordance with the highest professional standards. b. Standard of Care. i) The Provider shall exercise reasonable care and diligence in performing services under this Agreement in accordance with the highest generally accepted standards of this type of Provider practice throughout the United States and in accordance with applicable federal, state and local laws and regulations applicable to the DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Revised 04/23 2 performance of these services. Provider is solely responsible for the professional quality, accuracy and timely completion and submission of all work related to the Basic Services. ii) Provider shall be responsible for all errors or omissions of its agents, contractors, employees, or assigns 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. iii) The Provider shall not, except as otherwise provided for in this Agreement, subcontract the performance of any work under this Agreement without prior written permission of the County. No permission for subcontracting shall create, between the County and the subcontractor, any contract or any other relationship. iv) Provider is an independent contractor of County. Any and all employees of the Provider engaged by the Provider in the performance of any work or services required of the Provider under this Agreement, shall be considered employees or agents of the Provider only and not of the County, and any and all claims that may or might arise under any workers compensation or other law or contract on behalf of said employees while so engaged shall be the sole obligation and responsibility of the Provider. v) If activities related to the performance of this Agreement require specific licenses, certifications, or related credentials Provider represents that it or its employees, agents and subcontractors engaged in such activities possess such licenses, certifications, or credentials and that such licenses certifications, or credentials are current, active, and not in a state of suspension or revocation. vi) Should any documents, exhibits, or addenda be attached to this Agreement, the terms of this Agreement shall have priority in any conflict with or among the terms of such referenced documents, exhibits. vii) Should this Agreement involve project designs, the construction or creation of which is to be bid out or fulfilled by other contractors, and bidding or negotiation with contractors produce prices which, when added to the other elements of the approved total project cost, produce a cost that is in excess of the approved total project cost, the Provider shall participate with the County in negotiation and design adjustments to the extent such are necessary to obtain prices within the approved total project cost. All activity of the Provider with respect to these matters shall constitute Basic Services and shall be performed by the Provider without additional compensation. If negotiation and design adjustments fail to bring costs within the total project cost the County may reject all bids and Provider will redesign or reduce portions of the project in an effort to reduce the bid prices to within the total project cost and rebid the project. One such redesign is included within Basic Services. If this second letting for bids does not produce bids that are within the approved total project cost initially or after negotiations with the contractor the cost is not reduced to an amount within the total project cost, the Provider is not obligated to engage in further redesign. DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Revised 04/23 3 3. Basic Services a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows (fully describe services to be provided): b. To provide psychological testing and evaluations, parental competency evaluations, and interpretive sessions to identified Orange County Social Services clients involved with the Child Welfare Division. These evaluations will be provided to clients as required by Court Order or as determined necessary by Orange County Social Services Chile Welfare Division to assist with permanency planning and well-being needs. A final report will be prepared and provided to Orange County Social Services which becomes a part of the County's case file and cannot be released by the Contractor without the expressed, written permission of the County. Court testimony will be provided only if Contractor receives a subpoena to appear in Court. c. Provider rates are as follows: psychological evaluations $75/hour up to 16 hours/client, parental competency evaluations $75/hour up to 18-20 hours/client, court testimony $200/hour. The number of hours per client will be authorized by Orange County Social Services Human Services Manager for Child Welfare Division. d. Written evaluations/report should be provided to Orange County Social Services no later than 30 days after the last scheduled appointment with the client. 4. Duration of Services a. Term. The term of this Agreement shall be from July 1, 2023 to June 30, 2024. b. Scheduling of Services. i) The Provider shall schedule and perform its activities in a timely manner. ii) Should the County determine that the Provider is behind schedule, it may require the Provider to expedite and accelerate its efforts, including providing additional resources and working overtime, as necessary, to perform its services in accordance with the approved project schedule at no additional cost to the County. iii) The Commencement Date for the Provider's Basic Services shall be July 1, 2023. 5. Compensation a. Compensation for Basic Services. Compensation for Basic Services shall include all compensation due the Provider from the County for all services satisfactorily (as determined by the County) performed pursuant to this Agreement. The maximum amount payable for Basic Services shall not exceed Twelve Thousand Dollars ($12,000). Payment for satisfactorily performed Basic Services shall become due and payable within thirty (30) days of Provider properly invoicing County. Payment shall be subject to provisions of Section 5(b). b. Disputes. In the event the amount stated on an invoice is disputed by the County, the County may withhold payment of all or a portion of the amount stated on an invoice until the parties resolve the dispute. Should Provider fail to perform its duties under the DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Revised 04/23 4 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. c. Additional Services. County shall not be responsible for costs related to any services in addition to the Basic Services performed by Provider unless County requests such additional services in writing and such additional services are evidenced by a written amendment to this Agreement. 6. Responsibilities of the County a. Cooperation and Coordination. The County has designated (Crystal Mitchell) to act as the County's representative with respect to the Project who shall have the authority to render decisions within guidelines established by the County Manager or the County Board of Commissioners and who shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. Insurance a. General Requirements. Provider shall obtain, at its sole expense, Commercial General Liability Insurance, Automobile Insurance, Workers’ Compensation Insurance, and any additional insurance as may 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 consist of 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. 8. Indemnity a. Indemnity. To the extent authorized by North Carolina law the Provider agrees, without limitation, to defend, indemnify and hold harmless the County from all loss, liability, claims or expense, including attorney's fees, arising out of or related to the Project and arising from property damage or bodily injury including death to any person or persons caused in whole or in part by the negligence or 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 provision to require the Provider to indemnify the County to the fullest extent permitted under North Carolina law. 9. Amendments to the Agreement a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional compensation or a change in duration of this Agreement shall be made by a written Amendment to this Agreement executed by the County and the Provider. The Provider shall proceed to perform the Services required by the Amendment only after receiving a fully executed Amendment from the County. DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Revised 04/23 5 10. Termination a. Termination for Convenience of the County. This Agreement may be terminated without cause by the County and for its convenience upon seven (7) days’ prior written notice to the Provider. b. Other Termination. The Provider may terminate this Agreement based upon the County's material breach of this Agreement; provided, the County has not taken all reasonable actions to remedy the breach. The Provider shall give the County seven (7) days' prior written notice of its intent to terminate this Agreement for cause. Either party may terminate this Agreement upon notice to the other party that obligations pursuant to this Agreement are made impractical due to declarations of emergency by Orange County or by North Carolina due to events directly impacting Orange County. Both parties shall remain responsible for all payment and performance due up to the receipt of such notice, but shall have no further obligation or responsibility beyond that date provided the terminating party has taken all reasonable steps to complete the performance of its obligations. c. Compensation After Termination. i) In the event of termination, the Provider shall be paid that portion of the fees and expenses that it has earned to the date of termination, less any costs or expenses incurred or anticipated to be incurred by the County due to errors or omissions of the Provider. Upon request of the County, the Provider shall submit to County all relevant documentation, including but not limited to, job cost records, to support its claims for final compensation. ii) Should this Agreement be terminated, the Provider shall deliver to the County within seven (7) days, at no additional cost, all deliverables including any electronic data or files relating to the Project. d. Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. e. Suspension. County may suspend the Basic Services and this Agreement at any time for County’s convenience and without penalty to County upon three (3) days’ notice to Provider. Upon any suspension by County, Provider shall discontinue work on the Basic Services and shall not resume the Basic Services until notified to proceed by County. 11. Additional Provisions a. Limitation and Assignment. The County and the Provider each bind themselves, their successors, assigns and legal representatives to the terms of this Agreement. Neither the County nor the Provider shall assign or transfer its interest in this Agreement without the written consent of the other. DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Revised 04/23 6 b. 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 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. c. Non-Discrimination. 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 non-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.orangecountync.gov/departments/purchasing_division/contracts.php.) Any violation of the Orange County Non-Discrimination Policy 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. d. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. e. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. f. Severability. If any provision of this Agreement is held as a matter of law to be unenforceable, the remainder of this Agreement shall be valid and binding upon the Parties. g. Ownership of Work Product. Should Provider’s performance of this Agreement generate documents, items or things that are specific to this Project such documents, items or things shall become the property of the County and may be used on any other project without additional compensation to the Provider. The use of the documents, items or things by the County or by any person or entity for any purpose other than the Project as set forth in this Agreement shall be at the full risk of the County. DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Revised 04/23 7 h. 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 or 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 or non-appropriation of public funds. It is expressly agreed that County shall not activate this non-appropriation provision for its convenience or to circumvent the requirements of this Agreement. In the event of a change in the County’s statutory authority, mandate or mandated functions, by state or federal legislative or regulatory action, which adversely affects County’s authority to continue its obligations under this Agreement, then this Agreement shall automatically terminate without penalty to County upon written notice to Provider of such limitation or change in County’s legal authority. i. Signatures. 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. j. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Orange County Provider’s Name Attention:Nancy Coston Matala Psychological Services, PLLC P.O. Box 8181 7633 Wilderness Rd Hillsborough, NC 27278 Raleigh NC 27613-1628 [SIGNATURE PAGE TO FOLLOW] DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Revised 04/23 8 IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have hereunder set their hands and seal, all as of the day and year first above written. ORANGE COUNTY: PROVIDER: By: _________________________________ Bonnie Hammersley By: __________________________________ Kristy Matala, Owner/Psychologist Printed Name and Title DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Revised 04/23 9 ORANGE COUNTY—INTERNAL USE ONLY ______________________________________________________________________________ Finance Information Vendor Name: Matala Psychological Services, PLLC Vendor Contact Person: Kristy Matala Phone: 919-339- 1515 Address: 7633 Wilderness Rd City Raleigh State: NC Zip: 27613-1628 Department: Social Services Amount: $12,000 Purpose: psychological evaluations/court testimony Budget Code(s): 10400220- 761005/10405020-768000 Vendor # 63745 Vendor Status with NCSOS: Current-Active Vendor is a BOCC consultant: Yes No Contract Details Contract Type: New Amendment (Original Contract: ) (Most Recent Amendment ) Effective Date 7/1/23 End Date 6/30/24 Notice Date (Notice Purpose ) Award Approved by Board (Agenda Date: ); Made or Administered by Nancy Coston Signature Authority - BOCC Express Delegation (Agenda Date: ) - Policy 9.4: Under $5,000; Service Under $90,000; Construction Under $250,000 - Budget Policy Section XV (Capital Improvement Project: ) Bidding Informal Bidding ($30k-$90k); Formal RFP ($90k+); Other (<$30k); Exception(# ) Department Affirmation 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. Services related to this agreement have already begun or been completed. Description of the nature of the emergency condition that was addressed: Department Director’s Signature ________________________________________ Date: ________ Information Technologies This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Inapplicable because no hardware/software purchases or related services 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 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: Received for record retention: DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD 6/26/2023 8/18/2023 8/21/2023 8/21/2023 Revised 04/23 10 Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 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 NAME: Trust Risk Management Services, Inc PHONE (A/C, No, Ext): 877.637.9700 FAX (A/C, No): 877.251.5111 EMAIL ADDRESS: info@trustrms.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ACE American Insurance Company 22667 INSURED INSURER B: 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES (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) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A PER STATUTE OTH- ER $ E.L.EACH ACCIDENT $ E.L. DISEASE-EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A Each Incident Annual Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 06/20/2023 Trust Risk Management Services, Inc. doing business in NC as Potomac Risk Management Services, Inc. 1791 Paysphere Circle Chicago, IL 60674 Dr. Kristy L Matala 7633 Wilderness Rd Raleigh, NC 27613-1628 Orange County DSS 2501 Homestead Rd. Chapel Hill, NC 27516 Psychologist's Professional Liability Retroactive Date 09/29/2014 58G26405865 09/29/2022 09/29/2023 $1,000,000 $3,000,000 DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD 607 August 02, 2023 Dr. Kristy Matala 7633 Wilderness Rd Raleigh, NC 27613 1628 RE: Your Trust Endorsed Business Office Insurance Policy # G71879562 Dear Dr. Kristy Matala : Thank you for your support of the Trust Endorsed Business Office Insurance Program. The requested change to your policy has been processed and your policy has been endorsed to reflect this change. Enclosed please find a copy of the endorsement form. Please review this endorsement carefully and attach it to your original policy documents for the above referenced policy. Should you have any questions regarding this correspondence, or for additional information regarding further membership benefits and other membership insurance options, please be sure to contact us at 1.877.637.9700. Our professional staff is available to assist you Monday-Friday 8:30am-6:00pm (est)or visit our website at www.trustinsurance.com. You may also email us your questions at info@trustrms.com. Sincerely, Trust Risk Management Services, Inc. doing business in NC as Potomac Risk Management Services, Inc. DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Named Insured KRISTY MATALA Endorsement Number 001 Policy Symbol OGL Policy Number G71879562 Policy Period 07/22/2023 to 07/22/2024 Effective Date of Endorsement 07/22/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CC-1K11k (04/22) SIGNATURES THE ONLY COMPANY APPLICABLE TO THIS POLICY IS THE COMPANY NAMED ON THE FIRST PAGE OF THE DECLARATIONS. By signing and delivering the policy to you, we state that it is a valid contract. INDEMNITY INSURANCE COMPANY OF NORTH AMERICA (A stock company) BANKERS STANDARD INSURANCE COMPANY (A stock company) ACE AMERICAN INSURANCE COMPANY (A stock company) ACE PROPERTY AND CASUALTY INSURANCE COMPANY (A stock company) INSURANCE COMPANY OF NORTH AMERICA (A stock company) PACIFIC EMPLOYERS INSURANCE COMPANY (A stock company) ACE FIRE UNDERWRITERS INSURANCE COMPANY (A stock company) WESTCHESTER FIRE INSURANCE COMPANY (A stock company) 436 Walnut Street, P.O. Box 1000, Philadelphia, Pennsylvania 19106-3703 BRANDON PEENE, Secretary JOHN J. LUPICA, President _________________________________ Authorized Representative Insured Copy DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Insured Copy ALL-24627 (01/08) Policy Number THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMON POLICY CHANGE ENDORSEMENT Endorsement No.: Named Insured Endt Effective Date: 12:01 A.M., Standard Time Agent Name Agent No. Policy Eff Date: Policy Exp Date: This endorsement will not be used to decrease coverages, increase rates or deductibles or alter any terms or conditions of coverage unless at the sole request of the insured. COVERAGE PART INFORMATION --- Coverage parts affected by this change as indicated by x below. Commercial Property Commercial General Liability Commercial Crime Commercial Inland Marine The following item(s): Insured’s Name Insured’s Mailing Address Policy Number Company Effective/Expiration Date Insured’s Legal Status/Business of Insured Payment Plan Premium Determination Additional Interested Parties Coverage Forms and Endorsements Limits/Exposures Deductibles Covered Property/Location Description Classification/Class Codes Rates Underlying Exposure/Insurance is (are) changed to read {See Additional Page(s)} The above amendments result in a change in the premium as follows: This premium does not include taxes and surcharges. No Changes To be Adjusted at Audit Additional Return Tax and Surcharge Changes Additional Return Countersigned By: AUTHORIZED AGENT OGLG71879562 07/22/2023 07/22/2024 07-22-23 001 278988 TRUST RISK MANAGEMENT SERVICES INC DBA TRMS INSURA KRISTY MATALA ACE American Insurance Company X NO CHARGE X NO CHARGE NO CHARGE SEE NEXT PAGE DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Insured Copy ALL-24627 (01/08) Policy Number COMMON POLICY CHANGE ENDORSEMENT Endorsement No. Named Insured Endt Effective Date: 12:01 A.M., Standard Time Agent Name Agent No. Policy Eff Date: Policy Exp Date: POLICY CHANGES ENDORSEMENT DESCRIPTION (CONT’D) REMOVAL PERMIT If this policy includes the Commercial Property Coverage Part, the following applies with respect to the Coverage Part: If Covered Property is removed to a new location that is described on this Policy Change, you may extend this insurance to include that Covered Property at each location during the removal. Coverage at each location will apply in the proportion that the value at each location bear s to the value of all Covered Property being removed. This permit applies up to 10 days after the effective date of t his Policy Change; after that, this insurance does not apply at the previous location. OGLG71879562 07/22/2023 07/22/2024 07-22-23 001 278988 TRUST RISK MANAGEMENT SERVICES INC DBA TRMS INSURA KRISTY MATALA ACE American Insurance Company THE POLICY IS AMENDED AS FOLLOWS: ADD ADDITIONAL INSURED A PREMISES/OPERATIONS AND PRODUCTS/COMPLETED OPERATIONS ADDITIONAL INTEREST WITH THE FOLLOWING DESCRIPTION HAS BEEN ADDED: . THE FOLLOWING FORM(S) HAS BEEN ADDED: CC-1K11K 04-22 SIGNATURES THE FOLLOWING FORM(S) HAS BEEN ADDED: CG 24 04 12-19 WAIVER OF TRANSFER RIGHTS OF RECOVERY THE FOLLOWING FORM(S) HAS BEEN AMENDED: CG 20 26 12-19 ADDL INSD - DESIGNATED PERSON OR ORG ALL OTHER TERMS AND CONDITIONS REMAIN THE SAME DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Insured Copy LD-24639 (01/08) Policy Number Endorsement No. SCHEDULE OF GENERAL LIABILITY CHANGES Named Insured Effective Date: 12:01 A.M., Standard Time Agent Name Agent No. CLASS CODE INFORMATION AFFECTED BY THIS CHANGE IS ADDED, DELETED OR CHANGED AS INDICATED. THE FOLLOWING CLASS CODE INFORMATION IS: Code No. Premium Basis Premises/Operations Location Exposure Rate Premium Products/Completed Operations Rate Premium Classification: THE FOLLOWING CLASS CODE INFORMATION IS: Code No. Premium Basis Premises/Operations Location Exposure Rate Premium Products/Completed Operations Rate Premium Classification: THE FOLLOWING CLASS CODE INFORMATION IS: Code No. Premium Basis Premises/Operations Location Exposure Rate Premium Products/Completed Operations Rate Premium Classification: THE FOLLOWING CLASS CODE INFORMATION IS: Code No. Premium Basis Premises/Operations Location Exposure Rate Premium Products/Completed Operations Rate Premium Classification: OGLG71879562 07-22-23 001 278988 TRUST RISK MANAGEMENT SERVICES INC DBA TRMS INSURA KRISTY MATALA ACE American Insurance Company Additional Insured ALL 15.000 $ 15.00 FLAT CHARGE ADDED DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD CG 20 26 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2 POLICY NUMBER: OGLG71879562 COMMERCIAL GENERAL LIABILITY CG 20 26 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Wake County Government 301 South McDowell Street Raleigh, NC 27601 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1.In the performance of your ongoing operations; or 2.In connection with your premises owned by or rented to you. However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. This endorsement modifies insurance provided under the following: Insured Copy DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD Page 2 of 2 © Insurance Services Office, Inc., 2018 CG 20 26 12 19 POLICY NUMBER: OGLG71879562 COMMERCIAL GENERAL LIABILITY CG 20 26 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Orange County, NC 300 West Tryon Street P.O. Box 8181 Hillsboroough, NC 27278 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1.In the performance of your ongoing operations; or 2.In connection with your premises owned by or rented to you. However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. This endorsement modifies insurance provided under the following: Insured Copy DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: OGLG71879562 COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): Orange County, NC 300 West Tryon Street P.O. Box 8181 Hillsboroough, NC 27278 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV – Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. Insured Copy DocuSign Envelope ID: 7CBF367B-4F5C-4DA1-A542-6B5E57D6A1CD