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PROOF OF INSURANCE (2020) CLOSED0 � DATE (MMIDD/YYYY) CC)RV CERTIFICATE OF LIABILITY INSURANCE 2/19/2020 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: Concentra Unit The Graham The Graham Bui dingy PHONE M �m. t) 215-567-6300^ (FAX 1215-405-2694 1 Penn Square West _APPRg$%......ancentra UnitQqrahamqo.,,c,o,m........„ Philadelphia PA 19102- INSURER(S)AFFORDINGCOVERAGE ............. NA)Cm#,.,.,.,.,,.,. INSURER A: Columbia Casualty Company 31127 NCGRO-01 Occupational INSURER......... 11 I 262 �...tYnaS..Inco.....Dom•c'led ifornia, Health Centers of California,o � 23047 Fire Ins. Co.o 5 INSURER c •Alibied p entra, Inc. A Medical Corporation d/b/a Concentra, 4714 Gettysburg r dual WorldAssurance Ca a I I in �� ( �i 19489.... Mechanicsburg PA ce Cor oratio n INSURER E: Liberty Insurance 2404 43043 inNisu R ERF: Liberty Mutual Insurance Group 2 COVERAGES CERTIFICATE NUMBER: 883840395 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 RAID CLAIMS. ......... /LTR TYPE OF INSURANCE.... .......... , wvn POLICY NUMBER IMMIDDFY'YYYII llyOLICY EFF POLICY wyy Y'7 LIMIT......... S A X COMMERCIAL GENERAL LIABILITY Y HAZ4032244581-4 10/1/2019 10/1/2020 EACH OCCURRENCE $1,000,000 .__...,. _., .. ry _ — ..........................................._.. DAMAIuE:��s-LEa CLAIMS -MADE OCCUR ........ . ......J II„X,..II ...... .00,000 PRI ocq�grolu m).�, .. . X Professional Lia ...X... ,MED EXP (Any one person) $ 10„000 ^ ^ Claiml$ .$1.M......----...-3M..A.9,._... ,,, ,000 PERSONAL &ADV INJURY $1,000.0. GF:N`L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY .. JE(O LOC., PRODUCTS - COMP/2P AGG $ 3,000,000 OTHER: $ C AUTOMOBILE LIABILITY Y AS2-631-510199-329 10/1/2019 10/1/2020 C'OtABINE0 SINGL5. LVAI T $ 2,000,000 tE';d„accd;denlS X ANY AUTO BODILY INJURY (Per person) $ ....... OWNED SCHEDULED ... BODILY INJURY (Per accident . ( ) AUTOS ONLY HIRED AUTOS NON -OWNED OouoEkf DAMAGE $ AUTOS ONLY AUTOS ONLY t A . XUMBRELLALIAB X Y HMC 4032235752 10/1/2019 10/1/2020 EACH OCCURRENCE ,,,,,,,,,,,,,,,,,,,,,,,,••° 1-110,,000,000 . EXCESS L AB j CLAIMS-MADE O AGGREGATE . ( DED ( X I RETENTIONS, ry a Wn $ E WORKERS COMPENSATION WA7-63D-510199-359 10/112019 10/1/2020 STATUTE ERH I�� F AND WC5-631-510199-369 Y� 10/1/2019 10/1/2020 FYPRO RIE O / ARTTN/EI:UE7ECUTIVE E.L. EACH ACCIDENT $1,000,000 NIA Mandato m NH (mandatory ) LOYEEi $ 1,000,000 E.,L. DI,S,EA,S.E..:..EA,.EM.P.......... ........................... If yya;�w„ describe under LIMIT $ 1„000,000 DF.°SCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY B Property ZMD0119116-04 6/1/2019 10/1/2020 SEE BELOW D Excess Liability CO23701-005 10/1/2019 10/1/2020 $10M Each Occurrence $10M Aggregate DESCR$PTtON OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is re Quito d) UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis. Both Coverages are excess of a $3,000,000 Self -Insured Retention each Occurrence/Claim subject to a $10,000,000 Aggregate. PROFESSIONAL LIABILITY COVERAGE includes Case Management Services including the rendering of case management or utilization review performed by insured for others. INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-5; Effective 10/1/2019-10/1/2020 - $400,000 Each Medical Incident/$1,200,000 Aggregate Per Insured or Surgeon I See Attached... CERTIFICATE HOLDER CANCELLATION City of EI Segundo ATTN: David Serrano Director of Human Resources 350 Main Street EI Segundo CA 90245 i 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CONCGRO-01 LOC #: AC0WV ADDITIONAL REMARKS SCHEDULE Page 1—of 1 li4I.�. AGENCY NAMEDINSURED The Graham Company Occupational Health Centers of California, A Medical Corporation d'/b/a Concentra, Inc. POLICY NUMBER 4714 Gettysburg Rd. Mechanicsburg PA 17055 ....................... ............. CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL. REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244600-5; Effective 10/1/2019-10/1/2020 - $200,000 Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-5; Effective 10/1/2019-10/1/2020 - $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-5; Effective 10/1/2019-10/1/2020 - $200,000 Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-5; 10/1/2019-10/1/2020 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-5; 10/1/2019-10/1/2020 - $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions. WORKERS COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Policy #WA5-63D-510199-319; Effective: 10/1/2019-10/1/2020 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Policy #WA7-63D-510199-409 and WC7-631-510199-259; Effective: 10/1/2019-10/1/2020 ADDITIONAL WORKERS COMPENSATION POLICIES: OHC of Arkansas — Polic�+ #WC7.631.510199-289; Effective: 10/112019-1011/2020 OHC of Southwest (AZJUT') — Policy #WC2-631-510199-249; Effective: 1011/2019-10/112020 OHC of Delaware —Policy #WC2-631.510199-339; Effective: 1011/2019.1011/2020 OHC of GeorgWHawadd — Folio #WC2.631.510199-389; Effective: 10/112019.10/11.2020 OHC of Illinois — Policy #WC2 31-510199.419; Effective: 10/1/2019-10/1/2020 OHC of Louisiana — Policy #WC2-631-510199.299; Effective: 101112019-10/1/2020 OHC of Michigan Policy #WC2-631-510199.279; Effective: 1011)2019-101112020 OHC of Nebraska -- Polic, #WC2-631-51019'9.379; Effective: 1011120'19-1011/'2020 OHC of New Jersey Poky #WC2-631-510199-269; Effective: 1011/2019-1011112020 OHC of North Carolina -- Policy #WC7-631-510199-349; Effective: 1011/20'1'9-'1011/2020 OHC of Southwest (KS) —Policy #WC2-631-510199-429; Effective: 1011/2019-101112020 Therapy Centers of Sou'thwes't I, PA (OR) - Polic #WC2-63'1-510199.399; Effective: 1011/2019-10/112020 Therapy Centers of South Carolina, PA - Policy 1WC2-631-510199-309, Effective: 1011/2019-10/11/2020 OHC of Minnesota - Policy #WC2-63'1.510199.459; Effective: 101112016-1011/2020 OHC of Ataska -Policy #WC2-631-510199-449; Effective: 101112019-10/112020 CYBER LIABILITY - National Union Fire Insurance Company of Pittsburgh, PA - Policy #01-950-31-88; Effective 9/25/2019-2020 - Limit: $10,000,000 Security and Privacy EXCESS CYBER LIABILITY - Endurance American Insurance Company - Policy #PRX10009889402; Effective: 9/25/2019-2020 - Limit: $10,000,000 Each Occurrence/Aggregate Coverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured, but only for professional services performed) for or on behalf of the above Named Insured. Re: 390 North Sepulveda Blvd, EI Segundo, CA City of EI Segundo, CA; its officials, employees and or agents are additional insureds on the above General Liability, Auto Liability and Umbrella Liability Policies if required by written contract. Coverage provided to the additional insureds shall apply on a Primary / Non -Contributory Basis on the above General Liability, Auto Liability and Umbrella Liability policies if requiredby written contract. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: HAZ 4032244581-4 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSPIRED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION TO WHOM OR TO WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS IN A WRITTEN CONTRACT OR AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW. 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 c ontract 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 shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: HAZ 4032244581-4 032244581-4 COMMERCIAL GENERAL LIABILITY CG 20 0104 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTNER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number: AS2-631-510199-039 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name Of Person(s), Or Organizadon(s): Any person or organization whom you have agreed in writing to add as an additional insured, but only to coverage and minimum limits of insurance required by the written agreement, and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy. ,information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A-11. of Section III - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D,2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 0 Insurance Services Office, Inc., 2011 Page I of 1 255