ICRMA - The Regents of the University of California - 2021-0093INDEPENDENT CITIES RISK M ANAGEM ENT AUTHORITY
1802 Von Karman Ave., Suite 200, Irvine, CA92612
949.349-9882
Workers' Compensation Certificate of Coverage
Evidence of Coverage
Certificate Number: 2021-0093
Certificate Holder: The REGENTS OF THE UNIVERSITY OF CALIFORNIA, a Constitutional corporation, on behalf of the
University of California, UCLA Center for Prehospital Care Paramedic Education Program
(Attn:)
10990 Wilshire Boulevard, Suite 1450
Los Angeles, CA 90024
Covered Party: City of 0 Segundo
Description of
Covered Activity:
As respects Contract No. 4371 to provide clinical experience and observation opportunities of educational
value in the field setting for learning experience for Interns enrolled in the Program for the term of
07/01 /2021 to 06/30/2022.
Memorandum of
Coverage Number:
ICRMA WC 2022 Effective Date: 7/1/21 Expiration Date: 7/1/22
Limits:
$1,000,000 (per occurrence)
Member Retained
*$500,000
Lim it:
The Following
Workers' Compensation coverage as defined in the memorandum of coverage on file with the covered
Coverage is in
party named above.
effect:
This certificate is issued as a matter of information only and confers no rights upon the certificate holder.
This certificate does not amend, extend, or alter the coverage afforded by the Workers' Compensation
Memorandum of Coverage.
This is to certify that the coverage listed above has been issued to the Covered Party named above for the
coverage 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 coverage afforded as
described herein is subject to all the terms, exclusions, and conditions of the Workers' Compensation
Memorandum of Coverage of the ICRMA, w hich is available for your review upon request.
Coverage is in effectfrom 12:01 a.m. Pacific Standard Time of effective date to 12:01 a.m. Pacific
Standard Time of expiration date as stated above and will not be canceled, limited, or allowed to expire
except upon 30-day notice to the certificate holder.
Date Issued:
7/16/2021
Renewal:
No
Authorized Representative Signature