Loading...
PROOF OF INSURANCE (2023 - 2024) 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 C CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 05/23/2023 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 endorsemel PRODUCER Marsh Management Services Inc, NAM PHONE -.� ..FAX .-.,.. 2325 E Camelback Rd., Suite 600 t9IC EXIT-W ••--m•• "_. """"""•• -WNAM Phoenix, AZ 85016 E-MAIL .... R'ER S AFFCSRDING COVERAGE """ wNAIC —GLPL-23 24 INSURER A; Providence Assurance, LLC INSURED St, Joseph Health INSURER Bmm ....... .... „„„_,,. .._ ......•,,,•... __....,._.,... _... INSURER 1801 Lind Avenue SW #9016 JINSURER c :..._w._....................... Renton, WA 98057-9016 INSURER D INSURER E : ........... INSURER F rnvGonr_Gc RFRTIFICATF NIIMRFR— SEA-003880789-06 REVISION NUMBER: 0 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, LIMITS SHOWN MAY CONDITIONS E BEEN REDUCED BY PAID CLAIMS.___ EXCLUSIONS IONS OF SUCH POLICIES, YNPDDCONS _.m -" EFF POLICY EXP ILTR INSURANCE M IDDIYYYY MM)DWYYYY LIMITS A X COMMERCIAL GENERAL ILIA BILITY 1-14601-00-23 06101/2023 06/01/2024 EACH OCCURRENCE s 3,000,000 ElAtvtACL"�Yi1"R€ X CLAIMS -MADE OCCUR "T1 N� ,PRI M1S1`; fa ururcaIlwL ....$. — , MED EXP (Any one p r ong ......- -..—. - .. PER OVAL& ADV INJURY S _ GEN'LAGGREGAT E LIMIT APPLIES PER GENERAL AGGREGATE _ 5,000,00 $ 0 PRO- X POLICY LOC....... JLCT DUCTS COMPrOP AGG 'PRO... $ .,, _... OTHER COMBINED SINGLE t IMIT $ AUTOMOBILE LIABILITY ANY AUTO BODILY INJURY (Per person) $ " - OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS" HIRED NON -OWNED PROPrRIYOAMAGE $ AUTOS ONLY AUTOS ONLY Ptlr,9°" m UMBRELLALIAB OCCUR LAI�kdNGE $ EXCESS LIAB CLAIMS•MAr)E'' _"- AGGREGATE C1rrJ RE fEN'I°NC1N$ $ OTiH WORKERS COMP ENSATION $'�AT(L I:R.- . STR ..... ANDEMPLOYERS'LIABILITY Y f N ANYPROPRIETORIPARTNERIEXECUTIVE N / A N/A E L.'EACH ACi..(�1C.IudT .. _..$ .. .......,,,. OFFICERIMEMSER EXCLUDED? (Mande�1sacy In NH) '.. ELT DISEASE EAEMPLOYEE IT. �._ __... .a $ �. II e$ ddRSQ:I tllurrorJer. CIESCPtesc be un OPERATIONS below E L DISEA%E - POLtCY LIMIT 5 A Hospital Professional 1-14601-00-23 06/01/2023 06/01/2024 Each Claim 3,000«000 Liability Aggregate 5,000„000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Named Insured: Providence Medical Institute, 21311 Madrona Ave. Ste 101, Torrance, CA 90503 City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Human Resources THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street, Room 4 ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245-3895 AUTHORIZED REPRESENTATIVE © 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN118985706 LOC #: Seattle ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh Management Services Inc. Providence St. Joseph Health 1801 Lind Avenue SW #9016 POLICY NUMBER Renton, WA 98057-9016 CARRIER V NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liabili Insurance If this Certificate of Insurance is for Professional and/or General Liability insurance this provides evidence of coverage for 1) employees while acting within the scope and during the course of their employment with Providence St. Joseph Health and for 2) contracted parties for their acts, errors or omissions in rendering or failing to render Medical Services outlined by such contract with a Providence St. Joseph Health entity including the Insured identified on this certificate provided such contract requires coverage for the contracted parties. ACORD 101 (2008101) 0158-01-00-0001648-0002-0003628 © 2008 ACORD CORPORATION. All rights i The ACORD name and logo are registered marks of ACORD 0 Ate" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/26/2023 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, LLC. 1301 5th Avenue, Suite 1900 Seattle, WA 98101 CN118985706-Auto-23-24 _ _ _ INSURER A; SAFETY NATIONAL CASUALTY CORPORATION 15105 _.............,,,,. INSURED INSURER B : Providence Medical Institute �' .'�..... -. . mm— .. ....... 360 N. Sepulveda Blvd Ste 3000 INSURER C El Segundo, CA 90245 INSURER D : _-....._. INSURER E : ''...... INSURER F : r n1r1=1acic� CERTIFIrATF NUMBER: SEA-003552945-12 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. ... W WWWWWWWWWWWWWWWW .,.......� ._......_- INSR ----------------_ A�Jt�L ...,_.. ' POLICY-EFF... mPOLICY EXP LIMITS TYPE OF INSURANCE POLICYNUMBER MM/DD LTR. /1rXYY MWDD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1-11 A - I=. . ...- CLAIMS -MADE OCCUR I PREMISES (Ea occurrqnML_„ $„ MED EXP (Any one person) $ PERSONAL&ADVINJURY $ GEN1. AGGREGATE LIMIT APPLIES PER:GENERALAGGREGATE $ PRO - POLICY F1 JECT,,,,, LOC PRODUCTS - COMP/OP AGG $ $ OTHER: A AUTOMOBILE LIABILITY X CA 6676624 06101/2023 06101/2024 CCOMBINE4 INOLE LIMIT Ea aocutlenl ....... $ 2,000,000 X ANY AUTO AK, CA, MT, NM, OR, TX, WA BODILY INJURY (Per person) $ ._. SCHEDULED BODILY INJURY ( )Per accident $ A 03 ONLY HIRED NON -OWNED PA PERTY DAMAGE $ AUTOS ONLY AUTOS ONLY III •p!dnt) — ••••••• UMBRELLA LIAB OCCUR EACH OCCURRENCE $ ........-. EXCESS LIAB _ CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION STATUTE ERH_. .AND EMPLOYERS' LIABILITY YfN ANYPROPRIETOR/PARTNER/EXECUTIVE N N/A E L EACH ACCIDENT $ ._ OFFICER/MEMBEREXCLUDED? (Mandatory in NH) EA .DISEASE - EMPLOYE E,L..._...... E' If yes, describe under DESCRIPTION OF OPERATIONS below E L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) 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 _At 'P*t V 7ySS-LU76 AUUKU GUKrUKAI IUIY. Ali rlgnis reservuu. ACORD 26 (2016103) 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