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PROOF OF INSURANCE (2022 - 2023) CLOSEDif I D E N C E, Health & Services Providence Health & Services 1801 Lind Avenue SW #9016 Renton, WA 98057-9016 Providence Medical Institute 5315 Torrance Blvd., Suite A Torrance, CA 90503 Effective 6/1/03 Providence Health & Services Self -funded Professional and General Liability Program covers the employees of Providence Health & Services (PH&S) while acting within the scope and during the course of their employment with Providence Health & Services, for all acts that are normally covered by customary professional liability insurance policies. This program is continuous and does not expire; however, termination of employment terminates coverage for future acts. General Aggregate $ 4,Ut7L),UUU Professional and General Liability: Products - Comp/Op Agg $ Included Professional and General Liability, Errors and Personal & Adv Injury $ Included Omissions (malpractice) Each Occurrence $ 2,000,000 Contractual Liability, Managed Care, Fire Damage (Any one fire) $ Included Includes Fire Damage, Legal. Medical Expense (Any one Because this is funded through a PHS trust person) $ Included there is no "policy number" Coverage provided by Providence Health & Services Self -insured Professional and General Liability Program is continuous an applicable to all professional liability claims occurring while the Providence Health & Services employs the provider irrespective of when a claim Is made. Location: 360 N Sepulveda Blvd., Suite 3000, El Segundo, CA 90245 Additional Insured as respects to general liability: The City of El Segundo, Officials and Employees Certificate Issued with express authorization of Providence Health & Services, Martha Raymond, Vice President, Risk, Claims and Insurance. The City of El Segundo, Officials and Employees Attn: Administration Services 350 Main Street El Segundo, CA 60245 Date issued: January 5, 2017 This document Is conferred as information only, does not alter coverage afforded by the Self -Insurance Plan In any way, and guarantees the holder no rights beyond those extended in the policy.. T R� . V E N C Health & Services 1801 Lind Avenue SW #9016 Tel 425-525.3395 Renton, WA 98057-9016 Fax 425-525-3589 Email; cad q CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/01/2021 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 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 Marsh USA, Inc. 1301 5th Avenue, Suite 1900 Seattle, WA 98101 CN118985706-: AutD-21-22 INSURED Providence Medical Institute 360 N. Sepulveda Blvd Ste 3000 Ell Segundo, CA 90245 INSURER A(c A SAFETY NATIONAL CASUALTY CORPORATION 15105 a D: COVERAGES CERTIFICATE NUMBER: SEA-003552945-08 REVISION NUMBER: 2 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, ..._..... ...— — _............ ..... ...... ........................_... �_ _ LICY INTRR TYPE OF INSURANCE UI. POLICY NUMBER POLICYEFE MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ITm� CLAIMS-MADE..OCCUR PREMISES (Ea occu„r„rence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ . GEN'LAGGREGATE ..................... R: LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ JPRO- El LOC E.C'T PRODUCTS - COMP/OP AG $ $ OTHER A AUTOMOBILE LIABILITY X X CA 6675624 6-60112021 06/0112022 CCiI uBINLD rIN LE. LIMIIT .r(Ea accbden $ 2,000,000 .--------..,..._.. ..._..-._., X ANY AUTO AK, CA, MT, OR, TX, WA I BODILY INJURY (Per person) _ _ $ _............._ ----- OWNED SCHEDULED BODILY INJURY ( Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED -- PROPERTY DAMAIwE ... -•— $ AUTOS ONLY AUTOS ONLY ar ccldenl ------ .....L_` •••• mm•• $ UMBRELLA LIAR OCCUR L I EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I RETENTION $ $ WORKERS COMPENSATION ERH AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A E L EACH ACCIDENT $ .... . (Mandatory in NH) E,LDISEASE- EAEMPLOYEEI _ mmnn If yes, describe under LIMIT $ DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER 'S.rAlMk,I LLA I tVril City of El Segundo, Officials SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE and Employees THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Administration Services ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jean Aguirre %,,. V 7Jtfif-LU70 AI.VI[u �.VRrVRH 1IVIV. hu nyrrw rraCrv�u» ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AC DATE(MM/DD/YYYY) L --. CERTIFICATE OF LIABILITY INSURANCE 12/02/2021 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 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 Marsh USA Inc. 13C1 5th Avenue, Suite 1900 Seattle, WA 98101 CN118985706-00000-XSWC-22-23 .............................. INSURED Providence Health & Services 1801 Lind Avenue SW #9016 Renton, WA 98057-9016 INSURER A : INSURER C National CERTIFICATE NUMBER: SEA-003497940-11 REVISION NUMBER:. 2 15105 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. POLICYEFF P5-5d .____. --_ LISlit _ i�0 �VDCY EXP LT TYPE OF INSURANCE POLICY NUMBER MdDDI'Y'Y'YY. MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ OCCUR CLAIMS �....... �ATIi/1C MFAEN°Y ................... _.., -MADE PRFMISESLEaorcuLer1cp .... MED EXP (Any one erson) $ PERSONAL&ADVINJURY .............. _..... ._. $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S O- PRCT POLICY JC LOC PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE UMIT $ .. En accidrsn0 ......... .. ............................................... ANY AUTO BODILY INJURY (Per person) $ OWNED ULED BODILY INJURY $ AUTOS ONLY AUTOS (Per accident) HIRED NON -OWNED PROPERTYDAMAGE. $............................................... AUTOS ONLY AUTOS ONLY Per accdds a11m_ _. _....................... $ ........ UMBRELLA LIAB FICLAIMS-MADE OCCUR EACH OCCURRENCE ------------------------ $ EXCESS LIAB AGGREGATE $ DED RETENTIONS $ A WORKERS SP4065843 0110112023 X AND EMPLO ERSENSATION L ABILIITY Y 4 N SIR: $2,000,000 STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? M �N/A E L. EACH ACCIDENT $ 2,000,000 (Mandatory in NH) E L DISEASE - EA EMPLOYEE $ 2,000,000 If yes, describe under ____. _,_ _. ..., 2,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Providence Medical Institute, Internal Medicine El Segundo, 360 N. Sepulveda, El Segundo, CA 90245. Formerly Westchester Medical Group Center for Heart and Health. l,:tK 111-IL;A I t MULUtK The City of El Segundo, Officials and Employees ATTN: Administration Services 350 Main Street 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 REPRESENTATIVE 7�,1 2L.Srg 9"C' 01988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD C) COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December3l, 2021 we Member: Robert A, Reiss, MD Address: 360 Pacific Coast Hwy, Ste 3000, El Segundo, CA 90245 This cerlificate confinils that, LqTcA;flv(-- oil the coverage date belovk, 111C, above-flatiled physician is a mernber oi'the Couperalive of Ajncfictin Physicians, Inc. (CAP) and a Participant in the Mtitkial protection Trust (?Vffl`), MPT is an unincorporated organized under Califoniia hisurance Code section 1280,7. This certificate wilfers no rights upon the member and does not amend, extend or alter the coverage ;0orded under tic terms, conditions and exclusions of ille M"r Agreement. Membership Number Medical Specialty Coverage Date Retroactive Coverage Date 5906 Internal Medicine September 1, 1990 January 1, 1986 Subspecialty Sports Medicine, Primary Care Coverage (Claims made and paid) Current'Llmits of Liability $1.000.000 for all Claims based Medical Professional Liability Coverage upon an Occurrence $3,000.000 each calendar year aggregate The member must renwin a Member in good standing Or atrange for Tail Coverage for any Open or potential Clahn that may arise during the Coverage Pedod, Neither CAP nor MPT undertake any obligation to advise any party, other thaji the named member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. December 17. 2020 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2021 Member-: Allen Pachtman, MD Address: 360 Pacific Coast HNvy Ste 3000, El Segundo, CA 90245 , I Ilis certificate 0011filins tj)j'j(' eilbtflye on Ole coverage date below, the NbOve-118"led physician is a meniber of the Cooperative of American Physicillils, 1,ne, (CAp) alld a participant in the Mutual Protection Trust (Wo, 'Mph, is tarn unincon)orated interindemnity arrangement organized under California Insualuce Codc sc(,tion 12K7, This certificate coiflers no riglits j1pon O'le member and does not amend, e\1011(l or alter [lie Coverage afrorded Under the terms, conditions and exclusions, of the NFPT Agreement. embershlp Number Medical Specialty Coverage Date Retroactive Coverage Date 5908 Internal Medicine September 1, 1990 hainuwy 1. 1986 subspecialty Coverage (Claims made and paid) Current Limits of Liability Medical Professional Liability Coverage $1.000.000 for all Claims based upon an Occurrence $3.000.000 each calendar year aggregate 17he member must remain a Meniber in good standing, or arrange for Tail Coverage for any opell, or potential Claim that 111a e any obligation to advise arty party, otlier jht,111 tile narned arise during the Coverage Period, Neither CAP nor MPT undertak member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. December 17, 2020 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE COVeroge through December 31, 2021 Member- David M. Weiss, MD Address: 360 Pacific Coast Hw3, Ste 3000, El Segundo, CA 90245 This Certificate confirins that, eilbotive on the coverage dale below, the above-wimcd physician is a member of the Cooperative of AAncricun Physicialls, laic. (CAP) and a participant in the MUltual Protection Trust (MPT), MPT is an unincorporated interixideninity airangement organized under California histirance Code section 12803, "Phis certificate conrers Tao rights t1pon Ole member tind dots not amend, extend or alter the coverage affiorded under the lenns, conditions and exclusions ortl�je mrr Agreenient, Membership Number Medical Specialty Coverage Date Retroactive Coverage Date 8525 Internal Medicine November 1, 1997 None subspecialty Coverage (Claims made and paid) [Current Limits of Liability $1,000.000 for all Claims based Medical Professional Liability Coverage upon an Occurrence $3,000,000 each calendar year aggregate The mcniber must reinain 8 Member in good standing OF UrTallge for Tail Coverage for any open or potential Claim that may arise during the Coverage Period, Neither CAP nor mFr undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. December 17, 2020 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2021 Member: Gail Levee, MD Address: 360 N Sepulveda Blvd Suite 3000, El Segundo, CA 90245 This certificatc conrinlis that, cireCOW out the coverage date belmv, the above-narried phylicilltr is a member of the Cooperative of Anlerican 1'hYsi6als, hic, (CAI') and n participant to the MArtual Protection ',"rust (Mlyl'), IvIPT is an uldneorlmrated interinderwity wrall gcll jell t organized undel calif'onlia 111surance Code section 1280,7, This eerfificate, confers 110 igilts vapor -S not amend, extend or aller the coverage afforded under the teens, conditions and exclusions of the MPT tile Inernber arld dDL -)a Membership Number Medical Specialty Coverage Date Retroactive Coverage Date 34007 Internal Medicine October 1, 2019 None Subspecialty Coverage (Claims made and paid) Current Limits of Liability $1.000,000 for all Claims based Medical Professional Liability Coverage upon an Occurrence $3.000.000 each calendar year aggregate The niember must ret ' ilain a Member in 90NI standing or arrange for Tail Coverage for an), open or potential Chnni that may arise during the Coverage Period, Neither CAP'nor MPT tuldartake any obligation to advise^ tiny party, other tharl die named member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. December 17, 2020 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust