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PROOF OF INSURANCE (2021 - 2022) CLOSED (2)DATE (MMIDD/YYYY) ACCORD" CERTIFICATE OF LIABILITY INSURANCE 10/28/2021 1/4/2 2t 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(st. PRODUCER CONTACT Lockton Insurance Brokers LLC _ `PHON 777 S. Figueroa Street, 52nd Fl. FAX CA License #OF15767 E-MAIL Los Angeles CA 90017 INsuRER,11 AFFORDING COVERAGE-- (213)689-0065 INSURER A:Columbia Cattalt� ..3➢127 .._ NAIL It V CI�)�l�lmw. INSURED Vital Medical Services, LLC 1407912 700 North Brand Boulevard, Suite 220 Glendale CA 91203 INSURER C: State Cottnpensation Ins Fund of California 0'='a.1'IQ.IAk1 killIRARFR• 'VVI.+t` :'YYY GUVtKA"I=0 VI IIVIEVI 4 rti IIF1%0 I nvmva �.. ti ata, CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. 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. .. -, ....... �.., .. Nce......-- NSn -wY r.....HMA...40322POL181842CY MBER .....,.,.�. t TINSURANCE LS� LIMITS R rYY Mroa/2022 Y A L LIABILITY coMMERCIAOGENERA 1/5/202 EACH OCCURRENCE ..— Tit/iw1ItI 2 000 x � CLAIMS -MADE OCCUR Q. .._.—.. MED EXP An one n) .$ .Q ,C00 .,. ._...... .......... .... _—. PERSONAL & ADV INdJUARY s 2 000 000 ..._.— GaEN'L AGGREGATE LIMIT APPLIES PER: _ R: rxENERAL m. _..__.AGGREGATE .__ - $ 4G"0(} PRO- POLICY LOG X: JECT �C)P AGG PRODUCTS COMPd , '$ 4r:J' 1 C1R I OTHER: AUTOMOBILE LIABILITY NOT APPLICABLE t a tl I) VNULE LVM4T. $^ xxxxxx LL ANY AUTO BODILY INJURY (Per person) , ....... ... r � ... —. $ XXXX OWNED SCHEDULED BODILY INJURY (Per accident) $ XXXr XX AUTOS ONLY AUTOS HIRED NON -OWNED PROPEitTY DAhkAraL (E" °c1 °df 1�" $ XXXXXXX AUTOS ONLY AUTOS ONLY °°� $XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE '$ XXD�(xiX, EXCESS LIARETENG"IONS"CLAfMMADE, AGGREGATE —_ XXXX.Xxxxxx�... COMPENSATION PERT OTH XR B WORKERS Y 9l 16288-2020 10/28/2020 10/28/2021 TA ) TE AND EMPLOYERS' LIABILITY YIN E L EACH ACCIDENT $ 1 w10, 00 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEMMEMBIER EXCLUDED? 'I N / A ------" --" - (Mandatory In NH) E L. DISEASE EA EMPLOYEE $ I ,OV�'�,I,(%Q,,,,,, ....—... _.... ar IOF ixllow E.L. DISEASE- P $ 100000 A OPERATIONS Prof. RI N HMA 4032281842 1/5/2021 1/5/2022 $2,000 00 PerOClaimlMrl Claims Made-Retro Date FN $4,000,000 Aggregate 12/31/2015 DESCRIPTION OF OPERATIONS I LOCATIONS d VEHICLES (ACORD 101, Additionat Remarks Schedule, may be attached if more space is required) City ot` El Segundo Police Department is an additional insured to the cartent 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. 1RIt1MNlkl1l!id�lU�e'. 13864355 City Of E1 Segundo PO11Ce Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Lt. Jeff Leyman ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St El Segundo CA 90245 AUTHORIZED REP11 7 0^ ©1 1111-201 C 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 /5/2021 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 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 8:3640 Certificate ID: 138STATE J' A4 PPRSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS 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. 0.000-8 SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED mmmmmoms 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 Lu, Hank From: Alex Ghazalpour <alex@vitalmedicalservices.com> Sent: Monday, August 9, 2021 8:29 AM To: Lu, Hank Cc: Armen Vartanian Subject: Re: Question in regards to your insurance from the City of El Segundo Hank, This is to confirm that Vital Medical Services does not operate nor have any commercial vehicles and that all medical staff use personal vehicles. Additionally, all personal vehicles meet the minimum insurance requirements for California. Respectfully, Alex Ghazalpour Chief Operating Officer Vital Medical Services On Aug 9, 2021, at 8:08 AM, Lu, Hank <hlu@elsegundo.org> wrote: Lets make this easy, Please confirm by this email that Vita Medical Services does not have commercial vehicles and your staff will be using their personal vehicles. Additionally, all personal vehicles meets the minimum insurance requirements in CA.