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PROOF OF INSURANCE (2021 - 2021) CLOSEDDATE (MM/DD/YYYY) ACCORD® CERTIFICATE OF LIABILITY INSURANCE 1/5/2021 10/12/2020 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 Lockton Insurance Brokers, LLC I CONTACT NAME: 777 S. Figueroa Street, 52nd Fl. I PHONE CONN . Ext)* FAX Nor CA License #OF 15767 I E-MAIL Los Angeles CA 90017 ADDRESS: (213) 689-0065 I INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Columbia Casualtv COMDanv 31127 INSURED Vital Medical Services, LLC INSURER B: State Compensation Ins Fund of California 35076 1407912 700 North Brand Boulevard, Suite 220 I INSURER C : Glendale CA 91203 I INSURER 0: INSURER E: I INSURER F: COVERAGES VITME01 CERTIFICATE NUMBER: 13864355 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD wvD POLICY NUMBER (MM/OD/YYYYI (MM/OD/YYYYI A X COMMERCIAL GENERAL LIABILITY Y Y HMA4032281842 1/5/2020 1/5/2021 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE 1XI OCCUR DAMAGE RETE PREM SESO(Ea occur ence) $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY ❑PRO ❑LOC JECT PRODUCTS - COMP/OP AGG $ 4,000,000 OTHER: $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT (Ea accident) $ XXXXXXX ANY AUTO BODILY INJURY (Per person) $ XXXXXXX OWNEDSCHEDULED BODILY INJURY $ AUTOS ONLY AUTOS (Per accident) XXXXXXX HIRED PROPERTY DAMAGE $ XXXXXXX HNON-OWNED AUTOS ONLY AUTOS ONLY (Per accident) $XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAR HCLAIMS-MADE AGGREGATE $ XXXXXXX DED I I RETENTION $ $ XXXXXXX WORKERS COMPENSATIONPER Y OH X B AND EMPLOYERS' LIABILITY Y / N 9116288-2020 10/28/2020 10/28/2021 STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑Y N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1.000.000 A Prof. Liab. N N HMA4032281842 1/5/2020 1/5/2021 $2,000,000 Per Claim Claims Made -Retro Date $4,000,000 Aggregate 12/31/2015 DESCRIPTION OF OPERATIONS / 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. CERTIFICATE HOLDER 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 El Segundo CA 90245 AUTHORIZED REPR 7 ©1 88-2015 AC D CORPORATION. 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 ')83640 Certificate ID: 138MPPRSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE OCTOBER 28, 2020 AT 12.01 A.M. ALLEFFECTIVEDATESAREAND EXPIRING OCTOBER 28, 2021 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME VITAL MEDICAL SERVICES, LLC 700 N BRAND BLVD STE 220 GLENDALE, CA 91203 ..� 1 T s.rd III 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 YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET 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: SEPTEMBER 28, 2020 AUTHORIZED REPRESENTAfiIVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) 9116288-20 RENEWAL SC 8-84-99-54 PAGE 1 OF 2572 OLD DP 217