PROOF OF INSURANCE (2023) CLOSEDNo:653121413
This Certificate is provided to:
City of El Segundo
350 Main 'Street
El Segundo CA 90245
Return Address
UCLA Health System
757 Westwood Plaza
Los Angeles, CA 90095
UNIVERSITY OF CALIFORNIA
EVIDENCE OF SELF-INSURANCE
PROFESSIONAL LIABILITY & HOSPITAL LIABILITY
Type of Coverage N Self -Insured Limits
I. PROFESSIONAL MEDICAL AND HOSPITAL LIABILITY: 1,000,000 Each Occurrence
s,000,000 Aggregate
II. SPECIAL TERMS & CONDITIONS:
This certificate is issued in connection with, work� erfoN"med by:
Scott Mitnick at City of El Se undd,` 50, Main St, El Segundo, CA 90245
This certificate is only valid for ,work;p rfornied within the course and, scope of his/her employment within:
Center for P,rehospital Care at 6CL k al'th Systerr
University employees are provided a University: fended: defense and indemnification for alleged negligence
acts or omissions rising out oa'the,course and scope, t'tr'lhe,Univ,r rfy nployment except where they act or
fail to act because of �actual,fr'aud, colruptior), or, actual rnalice: (California Tort Claims Act. Government
Code Section 810).
2. The self-insurance evidenced horein ;follows -the provisions of the ylaW' s and Standing Orders of the
Regents of the University of Californiar"and "self-nsurande programs 'a administered by the University of
California, Office of the President,"Office,of'Risk Services, which do not permit any assumption of liability
which does not result from and i , not caused'by the pegligenl,ac or omissions of its officers, agents, or
employees. Any indemnification or hold harmless clause with broader`provlslons than required under such
Bylaws and Standing Orders shall invalidate'this certificate,
3. This certificate is in effect until the 'expiration 'dafe in icated'below or termination of applicable contract,
affiliation agreement or termination of Universlty`employment, whichever comes first.
Should any of the above described program of self-insurance be materially modified or cancelled before the
expiration date shown below, The Regents of the University of California will give 30 days written notice to the
certificate holder.
~
Effective Date: 07/01/2022 Johanna Klohn
UCLA Health System
7.57 Westwood Plaza
Los Angeles CA 90095
Expiration Date: 07/01/2023
Approval Date: 6/12/2022
This Certificate is issued as a matter of information only and confers no rights upon the certificate hinder. The Certificate does not
amend, extend or alter the coverage described above. This certificate does not constitute a contract between the holder and the
University of California.
Form: PL Individual 0914