PROOF OF INSURANCE (2022 - 2022) CLOSED0 DATE (MMIDD/YYYY)
" =' =- CERTIFICATE OF LIABILITY INSURANCE 1i5/2022 11/11/2021
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.
IMPORTANT: If the certificate holder its 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 ri tlts to the certificate holder in lieu of such endorsement s .
CONTACT
PRODUCER
Lockton Insurance Brokers, LLC NAM
777 S. Figueroa Street, 52nd Fl. PHa�NE
�c ttatla ..—......FAX
License #OF15767 EMAIL
Los Angeles CA 90017 .._
(213) 689-0065 INSURER A . Col Urn
AFFORDING COVERAGE L NAIC #
rnbia CtaSW1ItV COIT1D3r1Y 1127
140791- p ........ _
California )
2 7Vital 01 NorihtB and Blvd., LLC St 850 INstIFlEtt C State (:. t'+uaa erw^,atssfla Ins Fund o Cato ~~
INSURED INSURER
.... - _ .... .............._ .. ........�._..___..-- —. Glendale CA 91203 INsuRa=R
INSURER i
(INSURER F
RFVICInki MIIMRFR• "it it'VV)("1C)(
vTHIS •ISTOCERTIFY 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,
AND CONDITIONS OF SUCH POLICIES. BY PAID CLAIMS
SHOWN MAY HAVE BEEN RE _ _ m,,,m�„—__--_
oc�sUP�LIMITS
ICY E......
ILTEXCLUSIONS
P FF POLICY EXP LIMITS
TYPE OF INSURANCE POLICY NUMBER MOB
R MMlDD
A
X COMMERCIAL GENERAL LIABILITY
Y
Y
HMA 4032281842 1/5/2021
1/5/2022
EACH OCCURRENCE
$ 2 OOO OO0
. „
i N
$ 5.0000
CLAIMS -MADE L X.) OCCUR
MED EXP ({any one Person)
$ 5 OOO
PERSONAL & ADV INJURY
$
GEN'L AGGREGATE LIMIT APPLIES PER.
GENERAL AGGREGATE
4 000 OOO
$ � � w„
"o-
PC'Cb LOC
X POLICY
PRODUCTS - COMP/OP AG
$ 4 OQO,OOO ,,.
_
OTHER:
'..
$...._„
AUTOMOBILE
LIABILITY
NOT APPLICABLE
COMBINED SINGLE LIMIT _
Ira acc�60 1)$
}{X, {X
..
....
ANY AUTO
BODILY INJURY (Per person)
$ XXXXXXX
w...-_
OWNED-......
SCHEDULED
�,
BODILY INJURY (Per accident)XXXX
$ XXX
.m
AUTOS ONLY AUTOS
HIRED NON -OWNED
PR'UPF'RTY DAMAGEE
_
r $
__—...,
AUTOS ONLY ........, AUTOS ONLY
Paa a _1
_.
'
$ XXX3xxX
UMBRELLA LIAB OCCUR
NOT APPLICABLE
OCCURRENCE
EGGREGATE
$ XXXXXXX
— -...
'... EXCESS LIAB CLAIMS -MADE
..E ...mm ...,...__ ... .... ....._._.
AACH
$ XXXXXXX
DED RETENTION$
$ XXXX. XX
WORKERS COMPENSATION
�PER� OTH
B
Y
9116288-2021 10/28/2021
10/28/2022
............. . TE ER
(ACCIDENT
....
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
_E LL AT H
$ 1,000,000 _
OF EXCLUDED? Y
N / A
DISEASE - EA,E,M,PLOYEE
$ I: Q,QO,,OO,Q,,,__.....
(Mandatory in NH)
_EL. ...
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$ 1,000,000
A
Prof. Liab.
N
N
HMA 4032281842 1/5/2021
1/5/2022
$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)
THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S) REFERENCED..
City of El Segundo Police 'Depattrnent is an add tionlal 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 e ldorseinent(s) or policy language.
It-l1 Aa 1 IE FIULUCK
13864355
City of El Segundo Police Department
Attn: Lt. Jeff Leyman
350 Main St
El Segundo CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED
n 14RA 2D1.nCQtZD CORPORATION. All riahts 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
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 bythis 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.
83640 Certificate ID: 138MPPRSEMENT AGREEMENT
WAIVER OF SUBROGATION
BLANKET BASIS
SAN FRANCISCO EFFECTIVE 10/28/2021 AT 12.01 A.M.
ALL EFFECTIVE DATES ARE AND EXPIRING 10/28/2022 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
9116288-2021
RENEWAL
SC
HOME OFFICE 8-84-99-54
PAGE I OF 1
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
ommmmmma 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)
2572
OLD DP 217