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PROOF OF INSURANCE (2024 - 2024) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 09/20/2023 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 Management Services Inc. 2325 E Camelback Rd., Suite 600 Phoenix, AZ 85016 CN 1 18985706-GLPL-23-24 w§yj A: Providence Assurance, LLC NIA INSURED Providence St. Joseph Health INsRER e_ •• •• ...... ,,,........... 1801 Lind Avenue SW #9016 INSURER C - m........ ........... ........ Renton, WA 98057-9016_.-m........................�_.,.,.,.,. INSURER F COVERAGES CERTIFICATE NUMBER: SEA-003880789-07 REVISION NUMBER: 1 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. INSR A6.ff[ .............POLICY POLICY EFF POLNCY .xP `...... .... ... ..... .. .......-......_-...--. TYPE OF INSURANCE LTR NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY 1-14601-00-23 06/01/2023 06/01/2024 EACH OCCURRENCE $ 3,000,000 ......^.,,. OCCUR CLAIMS -MADE PREMSESnaoccu,.r„rP,,.,„_...-..- .....................................m...................... MED EXP (Any one person) S ................_._..,.,_.--................. NJURY PERSONAL B,ADV I............................ -,.............................. GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 X ...................................................... POLICY „PR LOC PRODUCTS-COMP/OPAGGw..V$ ......m.m.�.. ..........................................................._......................... OTHERS $ AUTOMOBILE LIABILITY C MBINEDSINGLE LIMB Ea accidle!r11 $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED .....� -� PROPERTY DAMAGE ���,., .,.,.,., _ .,....... _ AUTOS ONLY AUTOS ONLY _(Per accidaN $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ ],EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPL RS' LIABILIITY YIN ..................... STAR,LI,T.E,........_. - "' ..._ ...............-......................................... XECUTIVE N/A .E�L.�SEHAACCIDENT T .......$OFFICERIMEMBEREXCLUDED? .................................................................... ....... EMPLOYEE $ If yes, describe under ..,._ �....._......... ............................�. DESCRIPTION OF OPERATIONS. below E.L. DISEASE - POLICY LIMIT $ 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, maybe attached if more space is required) Westchester Medical Group-PMI Center for Heart and Health 360 N. Pacific Coast Hwy., Suite 3000 El Segundo, CA 90245 GtKIII`IVAIGFIVLUtK GANGtLL.AIIUN 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 of Marsh USA LLC � 79�Cc>urasC 2CSo�f ..L�.L�� ©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 C 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 NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability 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 /or 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) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r DATE (MMIDD/YYYY) 40PR1:> CERTIFICATE OF LIABILITY INSURANCE 09/21/2023 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 CONTACT MARSH USA LLC. - FAX ------___ 13015th Avenue, Suite 1900HOdp, LIIf1, __ iAI� Nef Seattle, WA 98101 E-MAIL CN118985706-0000-922-23-24 INSURED Providence St. Joseph Health 1801 Lind Avenue SW #9016 Renton, WA 98057-9016 CAVFRAr:FS CA r_FRTIFIr_ATF NIIMIi INSURER A: ,Safety NaIliggp,l INSURER B INSURER C INSURER D s INSURER E INSURER F SFA-nn3R428RR-nR AFFORDING COVERAGE RFVISIAN Nt1MRFR- 6 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 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ttPOLICIES. TYPEOFINSURANCE 1 POLIC.....,.................................... m..,�.,....,�.. . �..... LIMITS..........____ INSR AOOL 'IIR, YNUMBER �M�pDYEFF IAM/D2 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR P MED EXP (Any one person) .......$ ._PERSONALBADV $ .........................................�.,..,. INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL_ AGGREGATE $ POLICY ER LOC COMP/,MPI........____ OP AGG $ _PRODUCTS.11, $ — OTHE Zc A AUrOMOBILELIABILITY CA6675624 06/01/2023 66/11/2024 COMBINED SINGLE I. MIT $ 2,000,000 BODILY INJURY (Per person) $ X ANY AUTO AK, CA, MT, NM, OR, TX, WA OWNED SCHEDULED AUTOS ONLY - AUTOS HIRED NON -OWNED AUTOS ONLY ,.,.,.,., -.. AUTOS ONLY BODILY INJURY (Per accident) $ �(Peraccwe t) MAdE (Per accadom $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAS CLAIMS -MADE AGGREGATE $ ENTION $ $ A WORKERS COMPENSATION v / N ANYDPROPRIETOR/PAARTBILITYNER/EXECUTIVE OFFICERlMEMBER EXCLUDED? N ( n • ) (Mandatory m NH N/A SP4667422 .SIR: $2,000,000 (MT) SIR: $5,000,000 (AK,CA,OR,TX,WA) J 01/01/ 024 X PER OTH- E,LESTATUTE,,, ER .............................._...2 ACH ACCI N E.L DISEASE EA EMP mmmm _ EMPLOYEE _ 00 0,000 $ .... .$ .. a,0 2,000,000 DESCRIPTION If yes. describe under OPERATIONS below E.L. DISEASE- POLICY LIMIT $ ..e.... 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Westchester Medical Group-PMI Center for Heart and Health 360 N. Pacific Coast Hwy., Suite 3000 El Segundo, CA 90245 r'I=I2TIIZId_ATI- 14AI nm;i rAN(_FI I ATInN 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 of Marsh USA LLC. ?itazarc T.LSo�f .L�.L�� ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD