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PROOF OF INSURANCE (2020 - 2022) CLOSED----alll a DATE (MMIDDNYYY) CERTIFICATE OF LIABILITY RSpANVE 12/10/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONONLY AND CONFERS NOIGHTS 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. IMPORTAN'r if the certificate holder Is a 11 n ADDITIONAL INSURED , the ppa licy I (lea) 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 tights to the certificate holder In lieu of such andomement(s), CONTA& '' p .ins. PRODUCER NAME: alos Verdes ISU Insurance Services PHMO-A'Ntea: 955-5578 [FAX (800) 530-5726 WN11' Palos Verdes Ins., Agency Inc. ADDREft 314 Vista Del Mar, PO Box 636 INSURER($) AFFORDING COVERAGE NAIC 0 Redondo Beach CA 90277-0636 1 INSURER A: Ohio Security Insurance Co. 24082 INSURED INSURER 6: Allen Pachtman, Robert Reiss, Ivan Reed, INSURER C : David Weiss dba: Westchester Medical Group INSURER D: 360 N Sepulveda Blvd Ste 3000 INSURER E: ElSegundo CA. 90245 ­INSURERF, COVERAGES CERTIFICATE NUMBER. 2020-2021 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED . BELOW H I AVE BEEN ISSUED TO 1 HE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 AULIL'SLIUN LTR TYPE OF INSURANCE POLICY NUMBER INM WV0 NrOW) (l5_MrDhr%1 IM LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I s 2,000,000 CLAIMS -MADE 1 r;z;q 1%1 OCCUR DAMA6h I U RkN I IhU PREMISES (Eaomurmmo� pp 500.000 $ 15,000 MED EXP (Any one 00(w) $ A y BKS56298065 01/02/2020 01/0212021 PERSONAL 8. ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GENLAGGREGATE LIMITAPPLIES PER: POLICY 0 FILOC PRooucTS-COMP/OF`AGG $ 4,000,000 JPERCoT- OTHER: COMBINED SINGLE, LIMIT $ 1,000,000 AUTOMOBILE LIABILITY _(Ea aocldoW ANY AUTO BODILY INJURY (Per person) $ A OWNEDH SCHEDULED BAS56298065 01/02/2020 01/02/2021 BODILY IN $ AUTOS ONLY H RED IPer AUTOS ONLY AUTOS NON -OWNED 1 AUTOS ONLY PROPERTY DAMAGE adoNt) $ $ UMBRELLA LIAB rE;CH OCCURRENCE OCCUR EXCESS UAB CLAMS -MADE AGGREGATE I I $ DEC) RETENTION $ WORKERS COMPENSATION OTH. STPER ATUTE ER AND EMPLOYERS' LIABILITY YIN ANY PROPRIFTOPIPARTNERrcXECUTIVE E.L EACHACCIDENT OFFICERIMEMBER EXCLUDED? E] NIA (Mandatory In KIN) EL DISEASE -EA EMPLOYEE If `yeas, da&Wba und�ot DESCRIPTION OF OPERATIONS below E,L DISEASE - POLICY LIMIT I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) The Certificate holder is hereby named as additional insured with respects to general liability per form #CG 88 62 (0413) CERTIFICATE HOLDER CANCELLATION,,, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo, Officials and Employees ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 01988-201 b ACORD CORPORATION. All rights reserved. ACORD 25 (206103) The ACORD name and logo are registered marks of ACORD ti N COMMERCIAL GENERAL LIABILITY CG 88 62 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - BLANKET VENDORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Section II - Who Is An Insured is amended to include as an additional insured any person(s) or organiza- tion(s) (referred to throughout this endorsement as vendor) whom you have agreed to add as an additional insured in a written contract or written agreement, but only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business. 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 vendors, the following exclusions apply: 1. The insurance afforded the vendor does not apply to: a. "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agree- ment; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, except when unpacked solely for the purpose of inspection, demonstration, test- ing or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; e. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; f. Demonstration, Installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or h. "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (1) The exceptions contained in Subparagraphs d. or f.; or (2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. C. This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products. © 2013 Liberty Mutual Insurance CG 88 62 04 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 ,rs .PVfiir� �� Ir"ENCE I Health & Services CERTIFICATE OF INSURANCE •,ucer: Insured: Providence Health & Services i Providence Medical Institute 1801 Lind Avenue SW #9016 5315 Torrance Blvd., Suite A Renton, WA 98057-9016 Torrance, CA 90503 Effective 6/1/03 Providence Health & Services Self-funded Professional and General Liability Program covers the employees of Providence Health & Services (PH&S) while acting within the scope and during the course of their employment with Providence Health & Services, for all acts that are normally covered by customary professional liability insurance policies. This program is continuous and does not expire; however, termination of employment terminates coverage for future acts. Type . General Aggregate $ 4,000,000 Professional and General Liability: Products - Comp/Op Agg $ Included Professional and General Liability, Errors and Personal & Adv Injury $ Included Omissions (malpractice) Each Occurrence $ 2,000,000 Contractual Liability, Managed Care, Fire Damage (Any one fire) $ Included Includes Fire Damage, Legal. Medical Expense (Any one Because this is funded through a PHS trust person) $ Included there is no "policy number" Coverage provided by Providence Health & Services Self -insured -Professional and Generai Liability Program is continuous an applicable to all professional liability claims occurring while the Providence Health & Services employs the provider irrespective of when a claim Is made. Location: 360 N Sepulveda Blvd., Suite 3000, EI Segundo, CA 90245 Additional Insured as respects to general liability: The City of EI Segundo, Officials and Employees Certificate Issued with express authorization of Providence Health & Services, Martha Raymond, Vice President, Risk, Claims and Insurance. Certificate Issued To: The City of EI Segundo, Officials and Employees Attn: Administration Services 350 Main Street EI Segundo, CA 60245 Date issued: January 5, 2017 This document Is conferred as information only, does not alter coverage afforded by the Self -Insurance Plan In any way, and guarantees the holder no rights beyond those extended in the policy. Health & Services 1801 Lind Avenue SW #9016 Tel 425-525.3395 Renton, WA 98057-9016 Fax 425-525-3589 Email; �.x1�51..F)uaavir n¢ .nrq C:\UsersVp45 343\ DowMoads\TheCityofEISegyndo.doo CC>ARL> CERTIFICATE OF LIABILITY INSURANCE I D12/19/2019DnvyY► ATE I �. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA rIVELY 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). PRODUCERNAOTECT Marsh UInc 301 5th Avenue, Suite 1900 t HC v Exb; .... F ,f?91;— Seattle, WA 98101 E-MAIL Attn: Jennifer Caudebec - 206-214-3156 AP'PRE, S: 6 INSURER( )AFFORDINCOVERAGE CN118985706-00000-XSWC-19-22 INSURER A : Safety National Casualty Corp { 15105,,, INSURED INSURER B : Providence Health 8 Services •- 1801 Lind Avenue SW #9016 INSURER c_: Renton, WA 98057-9016 INSURER D: INSURER P: INSURER F : COVERAGESCERTIFICATE NUMBER: SEA -003497940-09 REVISION NUMBER: 2 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 — -- -- - j4bbL §U'd`k "" POLICY EFF POLICY EXP LTR TYPE OF INSURANCE Itt%R.-1DtlfjrC. POLICY NUMBER„ IMM/0DIYYYYI IMM/DD/YYYyl ii LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE$ w . ........ LN1'r'='r5..., . CLAIMS-f1ADE OCCUR „,,... PREIM,ISES,,(fa2caenre), $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY u PRO�'E'C1"' D LOC _ J PRODUCTS - COMPIOP AGG $ OTHER $ AUTOMOBILE LIABILITY COtW'BWED SINGLE LIMIT $ �a esz',cudentf ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (P''tr,accadentl UMBRELLA LIA3 NN ..mR LIAR CLAIMS-MA�E .... $EXCESS AGG EG,,ATE ......... ............................ ........... .._$.................. DED REI ELATION A WORKERS COMPENSATION ISP4059664 01/0112019 01101/2022 X I PER OTH- ... EMPLOYERS' LIABILITY YIN SIR: $2,000,000 _ EL`,.STATIJTE_ - _._ER 000,000 OPFCERPRIETOREXCNER/E ECUTIVF N NIA EACH ACCIDENT $ (Mandatory in NFI) I E L DISEASE - EA EMPLOYEE $ 2,000,000 If yes, describe under 2000,000 I DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ , DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Providence Medical Institute, Internal Medicine EI Segundo, 360 N Sepulveda, EI Segundo, CA 90245 Formerly Westchester Medical Group Center for Heart and Health, CERTIFICATE HOLDER CANCELLATION The City of EI Segundo, Officials and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Employees THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: Administration Services ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jean Aguirre „may - II ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD 0 COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE 1 1111 1 1 111 11 11 Coverage through December 31, 20201II Member: David M. Weiss, MD Address: 360 Pacific Coast Hwy. Ste 3000 El Segundo, CA 90245 This certificate confirms that, effective on the coverage date below, the above-named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement. Membership Number Medical Specialty 8525 Internal Medicine Subspecialty Coverage (Claims made and paid) Medical Professional Liability Coverage Coverage Date Retroactive Coverage Date November 1, 1997 None Current Limits of Liability $1,000,000 for all Claims based upon an Occurrence $3,000,000 each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any parry, other than the named member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. November 13, 2019 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust 0 COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2020 1 Member: Robert A. Reiss, MD Address: 360 Pacific Coast Hwy. Ste 3000 El Segundo, CA 90245 This certificate confirms that, effective on the coverage date below, the above-named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement. Membership Number Medical Specialty Coverage Date Retroactive Coverage Date 5906 Internal Medicine September 1, 1990 January 1, 1986 Subspecialty Sports Medicine, Primary Care Coverage (Claims made and paid) Medical Professional Liability Coverage r Current Limits or Liability $1,000,000 for all Claims based upon an Occurrence $3,000,000 each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. -.- 6�'..;,�.�" November 13, 2019 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust 0 COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2020 Member: Allen Pachtman, MD Address: 360 Pacific Coast Hwy Ste 3000 El Segundo, CA 90245 This certificate confirms that, effective on the coverage date below, the above-named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT), MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement, Membership Number Medical Specialty Coverage Date Retroactive Coverage Date 5908 Internal Medicine September 1, 1990 January 1, 1986 Subspecialty Coverage (Claims made and paid) Medical Professional Liability Coverage Current Limits of Liability $1,000,000 $3,000,000 for all Claims based upon an Occurrence each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period, Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. November 13, 2019 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust 01 COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage throughDecember31, 2020 Member: Gail Levee, MD Address: 360 N Sepulveda Blvd Suite 3000 EI Segundo, CA 90245 This certificate confirms that, effective on the coverage date below, the above-named physician is a member of the Cooperative of American Physicians, Inc, (CAP) and a participant in the Mutual Protection Trust (MPT), MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement. Membership Number Medical Specialty Coverage Date Retroactive Coverage Date 34007 Internal Medicine October 1, 2019 None Subspecialty i Coverage (Claims made and paid) Current Limits of Liability ' $1,000,000 for all Claims based Medical Professional Liability Coverage upon an Occurrence $3,000,000 each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. November 13, 2019 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust