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PROOF OF INSURANCE (2021 - 2022) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YWY) 10/28/2021 1/4/2021 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. IMSU ORTANT: 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). IPRODUCER Lockton Insurance Brokers, LLC1CONTACT 'NAME; 777 S. Figueroa CA License #0Fs576? S5767 E-MAItreetL f , 52nd Fl. _F�04E I— . flFAX .NC, r9o, Exil: IAIC. No�� Los Angeles CA 90017 ADDRESS: (213) 689-0065 'INSIlRe"RIS) MfcINNqovERAGE IN RER�A:C a '4$IA;1,Jty SU, .1. ___�QJUMb , i Q, 31127 INSURED Vital Medical Services, LLC INSURER B State CoMpensation Ins Fund of California 35076 1407912 700 North Brand Boulevard, Suite 220 INSURER C Glendale CA 91203 INSURER D: ... - — — ------ - ... lNSURER f COVERAGES VI'TMEOl 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. LTR TYPE OF INSURANCE ADDOSUSRr _, POLICY NUMBER valYv cy Yi LIMITS A COMMERCIAL GENERAL LIABILITY Y Y HMA 4032281842 1/5/2021 1/5/2022 EACH OCCURRENCE $ 2MO,000 CLAIMS -MADE F_V1 OCCUR AGGREGATE LIMIT APPLIES PER: POLICYF—] JP;ERCOT- D LOG OTHER AUTOMOBILE LIABILITY ANY AUTO 0 ..... . .. ... OWNED s 5.00(1.!:........-......— .000 SCHEDULED — AUTOS ONLY GENERAL AGGREGATE AUTOS HIRED $ 4,000,000 NON -OWNED — AUTOS ONLY NOTAPPLICABLE COIOMNEo' SINGLE LIMIT AUTOS ONLY UMBRELLA LIAB � OCCUR J EXCESS LIAB I CLAIMS,MADE � DED RETENMNS WORKERS COMPENSATION B AND EMPLOYERS' LIABILITY N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERWEMSER EXCLUDED? IN/A (Mandatory in NHI If os, describe wider '-CRIPT0N OF OF ERATIONS 11 - �(F4_pgr 0 ..... . .. ... nwn) MED EXP (Any oMne P. so s 5.00(1.!:........-......— .000 _RE &ADVINJURY ..R $ 2,00(�) GENERAL AGGREGATE $ 4,99Q,000 PRODUCTS -COMPMPAGG $ 4,000,000 DISEASE - POLICY LIMIT $ NOTAPPLICABLE COIOMNEo' SINGLE LIMIT $ xxxxxxx '.._ I'll BODILY INJURY (Per person) $xxxxx x x ' ' BODILY INJURY (Per accident)$ Xxxxxxx 1$ $ xxxXxxx NOT APPLICABLE Y 9116288-2020 ow A Prof. Liab. N N 11 HMA 4032281842 Claims Made -Retro Date 12/31/2015 1 10/28/2020 10/28/2021 1/5/2021 1/5/2022 I EACH OCCURRENCE $ xxxxxxx AGGREGATE . ....... xx�xxx , x " x . . ..... xxxxxxx PER I I OTH, $�Tm ___ - . ... . .......... EEACHACCIDENT E L. DISEASE - EA EMPLOYEE DISEASE - POLICY LIMIT $ 1.()0().(100 $2,000,000 Per Claim $4,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (ACORD 101, Addiflonat Remarks Schedule, may be attached If more space is required) ( , 'ity of El Segundo Police Department is all additional insured to the extent provided by policy language and/or endorsement(s) issued or approved by the insurance oart"ier. Waiver ol'Subrogallimi applies per attaclied endorsements) 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 Leyman THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main St ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo CA 90245 AUTHORIZED REPIR 'R7A 0 1 88-2010C 11 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: 1/5/2021 Forms a part of policy no.: HMA 4032281842 Issued to: Vital Medical Services, LLC By: Columbia Casualty Company ADDITIONAL INSUREDS ENDORSEMENT The Policy is amended as follows: Section 11. 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 11. 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) HC031 0 Attachment Code: D517303 Certificate ID: 13864355 STATE "83640 Certificate ID: 138 A�YPRSEMENT AGREEMENT CO MPEN SATION WAIVER OF i • • IN SUR ANCE BLANKET j : j SIS FUND HOME OFFICE SAN FRANCISCO EFFECTIVE OCTOBER 28, 2020 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND 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 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. PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER OF FOR WHOM THE NAMED INSURED SUBROGATION HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER 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 SCIF FORM 10217 (RkV.7-2014) AUTHORIZED REPRESENTAflIVE PRESIDENT AND CEO 9116288-20 RENEWAL SC 8-84-99-54 PAGE 1 OF MIA OLD DP 217