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PROOF OF INSURANCE (2020 - 2020) CLOSED0 DATE (MM/DD/YYYY) ACQRV CERTIFICATE OF LIABILITY INSURANCE 1/5/2020 I 10/4/2019, 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). CONTACT PRODUCER Lockton Insurance Brokers, LLC 6M 777 S. PHONEIV.00. . Fz -- Figueroa 52nd Fl.-ta Ex..............................LA.......... YC CA License #OF15767Ner, E-MAILE"MANE l . ........ ... . Los Angeles CA 900] 7 INSURER A : CQ�I1M.—i 1 RC7$11alty Op,,,,,, y 1 127 INSURED Vital Medical dica 0065 Services, L INSURER B: State Compensation Ins Fund 0 California 35076, 1407912 550 North Brand Boulevard, Suite 1850 INSURE Vital Glendale CA 91203 INSURER D t INSURER E: INSURER F: COVERAGES VITME01 CERTIFICATE NUMBER: 131164355 REVISION NUMBER: XXXXXXX 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. iNBR TYPE OF INSURANCE .....,,iAaa Suo- POLICY EFF 'i P6-1- CY EXP i .,LIMITS ... LTR IN-tn WVD POLICY NUMBER (MMIDDIYYYYI PMMIODSYYYYtl A X _ Y Y HMA 4032281842-3 1/5/2019 1/5/2020 2,000.000 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ I CLAIMS -MADE (X. OCCUR . 5.0.,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ „5,000 X POLICY PRO,LOC $ 2,000,,,000 JECr $ µ000_z000_ 4. 01 HER $ 4,000,000 AUTOMOBILE LIABILITY NOT APPLICABLE ANY AUTO $ XXXXXXX OWNED SCHEDULED $ XX.X.X.XXX AUTOS ONLY AUTOS PROPERTY DAMAGE (Pet arddent) HIRED NOWOWME'D AUTOS ONLY AUTOS ONLY UMBRELLA LIABOCCUR k. NOT APPLICABLE EXCESS LIAR CLAIMS -MADE 1 AGGREGATE DED I I RETENTION $ WORKERS COMPENSATION Y AND EMPLOYERS' LIABILITY B Y/ N 9116288-2019 ANY PROPRIETOR/PARTNER/EXECUTIVE E,L;,EACHACCIDENT OFFICER/MEMBER EXCLUDED? ❑Y N/A _$__I'000,T0„O,0,,,,,,,,,,, EL DISEASE EAEMPLOYEEI_$ 1,000,00,0 (Mandatory in NH) $ 1,000,000 If yes, describe under 11/5/2020 DESCRIPTION OF OPERATIONS below A Prof. Liab. N N HMA 4032281842-3 Claims Made -Retro Date 12/31/2015 1%98�Ct tU N E'N1 ED PR'CP,S IE,d occ arranca�. . 5.0.,000 MED EXP (Any one person) $ „5,000 PERSONAL &ADV INJURY $ 2,000,,,000 GENERAL AGGREGATE $ µ000_z000_ 4. PRODUCTS - COMP/OP AGG $ 4,000,000 $ COM81NFO V.IMfP $ XXXXXXX BODILY INJURY (Per person) $ XX.X.X.XXX BODILY INJURY (Per accident) $ XXXX,XXX,,,, PROPERTY DAMAGE (Pet arddent) ! $ XXXXXXX $XXXXXXX EACH OCCURRENCE $ XXXXXXX „ AGGREGATE $ X,XXXXXX $XXXXXXX PER L..X PRH 10/28/2019 10/28/2020 STATUTE E,L;,EACHACCIDENT _$__I'000,T0„O,0,,,,,,,,,,, EL DISEASE EAEMPLOYEEI_$ 1,000,00,0 E L DISEASE - POLICY LIMIT $ 1,000,000 1/5/2019 11/5/2020 I $2,000,000 Per Claim $4,000,000 Aggregate DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 107, Additional Remarks Schedule, maybe attached if more space is required) City of El Segundo Police Department is an additional insured to the extent provided by policy language and/or endorsement(s) issued or approved by the insurance carrier. Waiver of Subrogation applies per attached endorsement(s) or policy language, CERTIFICATE HOLDER 13864355 City of El Segundo Police Department Attn: Lt. Jeff Leyman 350 Main St El Segundo CA 90245 AUTHORIZED REPR ©168-2.01 CfD ORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CANCELLATION See Attachments SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016/03) ENDORSEMENT NO. L01 This endorsement, effective 12:01 AM: 1/5/2019 Forms a part of policy no.: HMA 4032281842-3 Issued to: Vital Medical Services, LLC By: Columbia Casualty Company ADDITIONAL INSUREDS ENDORSEMENT The Policy is amended as follows: Section II. WHO IS AN INSURED 01 the HEALTHCARE PROFESSIONAL LIABILITY COVERAGE PART is amended by adding the following: but only as respects liability arising out of the conduct of your business. Section II. WHO IS AN INSURED 01 the HEALTHCARE GENERAL LIABILITY COVERAGE PART is amended by adding the following: but only as respects liability arising out of the conduct of your business. All other terms, conditions and exclusions of the policy remain unchanged. 79523( 5/02) HC0310 Attachment Code: D5I7303 Certificate ID: 13864355 Attachment Code: D539987 Certificate ID: ] 3864355 STATE v -RIVER OF SUBROGATION BLANKET BASIS FUND HOMEOFFICE SAN FRANCISCO EFFECTIVE OCTOBER 28, 2.019 AT 12.01 A.M. AND EXPIRING OCTOBER 28, 2020 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME VITAL MEDICAL SERVICES, LLC 550 N BRAND BLVD STE 1850 GLENDALE, CA 91203 WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN INJURY COVERED BY THIS POLICY. WE WILL NOT ENFORCE OUR RIGHT AGAINST THE PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT Yol PERFORM OBTAINYOU TO PERSON OR ORGANIZATIONJOB _..m._..............•__� DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER OF SUBROGATION NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: OCTOBER 8, 2019 2572 SCIF FORM 10217 IREV 7-2014) OLD DP 217