PROOF OF INSURANCE (2022 - 2023) CLOSEDDATE (MMIDD/YYYY)
CERTIFICATE LIABILITY INSURANCE
to/za/zozz 2/1/02
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
NpAa�ru 111
ME.
777 S. Figueroa Street, 52nd Fl.
PH
E>tl
CA License #OF] 5767
E-MAIL
Los Angeles CA 90017
AQQ69ss
(21 3) 689-0065
(S) AFFORDING COVERAGE
INSURERINSURERA
NAIC #
�,A................ ; Endurance American Specialty Insurance Co.
41718 —
.
INSURED Vital Medical Services. LLC
INSURER B : State Compensation Ins -Fund -of California
35076
1407912 701 North Brand ffivd-, Ste 850
INSURER
Glendale CA 91203
INSURER D :
INSURER E
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.
LTR TYPE OF INSURANCE IN WV ,.„
POLICY EFF POLICY EXP
POLICY NUMBER MMIDD/YYYY MM/DDIYYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY y Y
HLA10015296800 2/15/2022 2/1 5/2023 EACH OCCURRENCE
s 2.000,000
CLAIMS -MADE XOCCUR
`fSAit!1AuE=1U1tENPED_
PREMISES„lEa oroyrrer,ce),
-.
, $ SO,000 ,,,,
p MED EXP (And one person)
$ „5.000
PERSONAL & ADV INJURY
s 2.000.000
G.....
EN'LAGGREGATELIMIT APPLIES PER.
GENERAL AGGREGATE
s 4.000.000 _
,PRO
X , POLICY JEC LOC
PRODUCTS - COMP/OP AGO
$ 4 000 OOO
OTHF�R.:.
s
___................._.....-.-..
__
AUTOMOBILE LIABILITY
�.........,.Y....._.,_.�,�
NOT APPLICABLE COMBINED SiNG4.D w.udir
$ XXXXXXX
m
ANY AUTO
person)
BODILY INJURY (Per accident)
$ XXXXXXX
OWNED SCHEDULED
BODILY INJURY (Per a
$ XXXXXXX
XX
. AUTOS ONLY AHIRED UTOS
ItCVPc ANIA/„
$ XXXXXXX
AUTOS ONLY AUTOS ONLDY
, g du a
..
I
SXXXXXXX
UMBRELLA LIAB OCCUR
.�.._
NOI APPLICABLE EACH OCCURRENCE
s XXXXXXX
.._
EXCESS LIAB CLAIMS -MADE
:. AGGREGATE
s .XXXXXXX
�._.� ,...,. _ ,.a.,.,.
UED RETENTIONS
. _
.....
S XXXXXXX
WORKERS B Y
PER H
TE
9116288-2021 10/28/2021 10/2.8/2022 STATUELL
EMPLOYERS' ABILITY
FRX
AND cuTlvE �YIN
EACH ACCIDENT
$ l 000 000
OFFICER/MEMBER EXCLUDED? - u N I A
(Mandatory in NH)
EL DISEASE - EA EMPLOYEES_If
l 000,QO0
yes, describe under
DESCRIPTION OF OPERATIONS below
E L.. DISEASE -POLICY LIMIT
$ 1.000,000
A Prof. Liab. N N
HLA10015296800 2/15/2022 2/15/2023 $2,000,000 Per Claim
Claims Made-Retro Date
S4,000,000 Aggregate
12/31 /2015
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may he 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 carver
Waiver of Subrogation applies per attached endorsement(s) or policy language,
CERTIFICATE HOLDER
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 REPREI3E11"I
0)1 58-201 nCGrkD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
ENDORSEMENT NO. L01
This endorsement, effective 12:01 AM: 2/15/2022
Forms apart of policy no.: HLA10015296800
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@vitaimedicalservices.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.
Respectfu I ly,
Alex Ghazalpour
Chief Operating Officer
Vital Medical Services
On Aug 9, 2021, at 8:08 AM, Lu, Hank <hlu@elsegundo.org> wrote:
Lets makethis 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.
FNn RSEMENT AGREEMENT
$83 0 Certificate ID: 1386435�
. WAIVER OF SUBROGATION
BLANKET BASIS
SAN FRANCISCO EFFECTIVE 10/28/2021 AT 12.01 A.M.
ALL EFFECTIVE DATES ARE AND EXPIRING 10/28/2022AT 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 1 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
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, 220020
2572
AUTHORIZED REPRESENTAfiIVE PRESIDENT AND CEO
SQF FORM 10217 (REV.7-2014)
OLD DP 217