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PROOF OF INSURANCE (2020 - 2021) CLOSEDDATE(MMIDD/YYYY) AC"R " CERTIFICATE OF LIABILITY INSURANCE 10/28/2020 12/30/2019 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 confer rights to the certificate holder in lieu of such endorsement(s). this certificatedoes Insurance CONTACT PRODUCER e Brokers, LLC NAME' 777 S. Figueroa Street. 52nd Fl. PHONE FAX CA License #OF15767 E-MAIL Los Angeles CA 90017,ADDREwS..:.................................................... ......�.. E , NAIc.#................ INSURER 213) 689-0065 INSURER A :Columbia Casualty Company om a COVERAGE ( n. .... ... �' 11 .... 31127 INSURED Vital Medical Services. LLC INSURER B: State Compensation Ins Fund of California 35076 1407912 550 North Brand Boulevard. Suite 1850 INSURER C Glendale CA 91203 INSURER D: INSURER E : INSURER F; COVERAGES VITMEO1 CERTIFICATE NUMBER: 1.3864355 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 LTR ....,,,, INSn �SUBst- POLI „ NSR TYPE OF INSURANCE �INSD I WVD POLICY NUMBER (MMIr10Y� POLICY EXP LIMITS C l (MMIDD/YYYYII RAL LIABILITY y y I-tMA4032281842 1/5/2020 1/5/2021 I EACH OCCURRENCE $ 2.000,000„ CLAIMS -MADE X OCCUR bAMAUf=°10RENTED A X I COMMERCIAL NE PREMISES „(Ea occur r,,price,)$ 50,000 , MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 270001.000 GEPJ'L AGGREGATE LIMIT APPLIES PER: GENERATSGGREGATECOMP ®P AGO II, S 4,000,000 00 i "RD'° L ,. POLICY LOCPRODUC OTHER $ AUTOMOBILE LIABILITY NOT APPLICABLE L )„ $ XXXXXXX 1BODILY ANY AUTO INJURY Per person) R OWNED SCHEDULED (Per } $ XXXXXXX BODILY INJURY (Per accident ,.,.._._... AUTOS ONLY HIRED AUTOS NON -OWNED $ XXXXXXX P°aOPFR"Y XXXXXX _.. AUTOS ONLY .. AUTOS ONLY ,,,(Per ocz)cent,) sXXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE URRENC E $XXXXXXX _I EXCESS LIAB CLAIMS -MADE E AGGREGATE $ XXXXXXX DED I V RETENTIONS $ XXXXXXX WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY B Y 9116288-2019 PER III 10/28/2019 10/28/2020 X PER j YIN ANY ECUTIVE E L EACH ACCIDENT 00 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E L DISEASE - EA EMPLOYEE.' $ 1 000 Qp If yes, describe under I DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ 1 .000.000 0 A (Prof Liab N N HMA4032281842 1/5/2020 1/5/2021 $2,000,000 Per Claim I Claims Made -Retro Date $4,000,000 Aggregate 12/31/2015 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be 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 CERTIFICATEHOLDER CANCELLATION See Attachments 13864355 City of El Segundo Police Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Lt. Jeff Le man THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St EI Segundo CA 90245 AUTHORIZED REPReleWrAIM ©186-20'1 C DC All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT NO. L01 This endorsement, effective 12:01 AM: 1/5/2020 Forms a part of policy no.: HMA4032281842 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: D517303 Certificate ID: 13864355 Attachment Code: D539987 Certificate ID: 13864355 . . ..................... ---- STATE WAIVER OF SUBROGATION BLANEET BASIS FUND HOME OFFICE SAN FRANCISCO EFFECTIVE OCTOBER 28, 2019 AT 12 . 01 A o 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, SERVICF]S, LLC 550 N BRAND BLVD STE 1850 GLENDALE, CA 91203 WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM .ANYONE LTABLE FOR AN INJURY COVERED BY Tll I S POLICY. WE WILL NOT ENFORCE OUR RIGHT AGAINST THE .PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. THIS AGREEMENT APPLIES ONLY TO THEE EXTENT TJlAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PPEMIUM FOR TFITS ENDORSEMENT SHALL BE 2.00%, OF' THF� TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION JOB -111, . .................................... DESCRLP'FION ANY PERSON OR ORGANIZATION BLANF�ET 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