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PROOF OF INSURANCE (2026 - 2026)
DATE (MM/DDIYYYY) COR CERTIFICATE OF LIABILITY INSURANCE �. 8/1 /2025 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 endorsements . PRODUCER �� _- . It Graham Company, PHONE Con'centra Unit .. ... WWWW NAME; CONTACT AX a Marsh &McLennan Agency, LLC company 15-567 630i1 N+Nr 405 24 IwPAR9 Congentra Unit@ot" grahamearo RqM 30 S 15th Street, 20th Floor .E . ____ •_-- Philadelphia PA 19102 INSUREI_(SIAFFORDINGCOVg!!AGE_mmmm NAIC# INSURER A: Columbia Casualty Comp any_mmmmmmmmmm �._.,,. 31127 Occupational Health Centers of California, corlccRo-ii1 irNisuRERc: AlledwWorld Assurance Ins. Co 23035 INSURED _..--. .......................... Mutual .... SURER B: A Medical Corporation Company AG dba Concentra Medical Centers INsuRERD: Employers Insurance of Wausau ......... .. r21458 5090 Spectrum Drive, Suite 1200 West INSURERE: LM Iwnsurance Corporation 33600 Addison TX 75001 - ... INSURER .F; Libe Insurance Corporation 42404 coTrCIrATC KIN iReQCD.4a7aQ1')Q3n Pr�="UL inm tJIIMRr-R- 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. ........................--------- ....... ............ ........................m..-,.,-.-.,....._,.-..........._......,.,. IINSR ADDL S'�UBR POLICY EFF PO CDY EX.P LIMITS LTR TYPE OF INSURANCE POLICY NUMBER M�1d1A A X COMMERCIAL GENERAL LIABILITY Y Y HAZ4032244581-9 1/1/2025 1/1/2026 EACH OCCURRENCE $1000000 CLAIMS -MADE OCCUR -PREMISES a ayc$ 500 000-mmIT m X '.. Professional Lia MED EXP (Any one person) $ .a..�................. .--.........-.... ............. X $1 M Claim/$3M Ag PERSONAL 8 ADV INJURY $ 1,000,000 .. GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY ❑PRO- ❑ LOC PRODUCTS - COMP/OP AGG $ 3,000,000 JECT .........._............._. OT HEfr B AUTOMOBILE LIABILITY Y Y AS2-631-510199-325 4/1/2025 4/1/2026 MBINED SINGLE LIMIT s2,000,000 X ANY AUTO BODILY INJURY (Per person) -BODILY $ ... OWNED SCHEDULED INJURY (Per accident) $ .-_m... AUTOS ONLY „„,.„„„„,,, AUTOS HIRED NON -OWNED PROPERTYDAMAGE . ........ $ AUTOS ONLY AUTOS ONLY P a 4,ntj _•••••• •-.•••-----....- A X UMBRELLALIAB X OCCUR ........ Y Y HMC4032235752 1/1/2025 1/1/2026 EACH OCCURRENCE $9,000IT000 '.. EXCESS LIAB X CLAIMS -MADE AGGREGATE ...._......................... $ 10,000,000 OED X RETENTION $ $ F WORKERS COMPENSATION Y WA7-63D-510199-355 4/1/2025 4l1/2026 ? PER OTH- E AND EMPLOYERS'LIABILITY YIN WA5-63D-510199-315 4/1/2025 4/1/2026 _ -sTArur� ..ER ...._�. ANYPROPRIETOPJPARIhgErVEr�'EC; (XTgVE. BE OFFICERdMEMEYEREXCi.IJDED"� N / A E L EACH ACCIDENT .........---�... $ 1,000,000 ..._ (Mandatary In EL DISEASE -EA EMPLOYEE $1 000000 If y, describe under DE:"a"CRtlPTION OF OPERATVONS below iE.L. DISEASE- POLICY LIMIT $ 1,000,000 D C Pro errt Excess liability YAC-L9L-477341-015 CO23701I010 1/1/2025 1/1/2025 1/1/2026 1/1I2026 SEE BELOW 110M Each occurrence $10M Aggregate DESCRIPTION OF OPERATIIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) PRIMARY LIABILTY POLICY includes General Liability Coverage on an Occurrence Basis and Professional Liability Coverage on a Claims Made Basis. UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis. Both Coverages are excess of a $3,000,000 Self -Insured Retention each Occurrence/Claim subject to a $18,000,000 Aggregate. INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-11; Effective 1/1/2025-1/1/2026 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon See Attached... HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. ATTN: David Serrano Director of Human Resources /AtJ„TPORLZED UPR£SENTATIVE 350 Main Street El Segundo CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CONCGRO-01 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMEDINSURED Graham Company, Occupational Health Centers of California, A Medical Corporation POLICY NUMBER dba Concehtra Medical Centers 5080 Spectrum Drive, Suite 1200 West Addison TX 75001 CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - 11 Continental Casualty Company - Policy #HAZ 4032244600-11; Effective 1/1/2025-1/1/2026 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-11; Effective 1/1/2025-1/1/2026 - $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244628-11; Effective 1/1/2025-1/1/2026 - $800„000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-11; 1/1/2025-1/1/2026 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon W$SCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-11; 1/1/2025-1/1/2026 - $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions. WORKERS COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Liberty Mutual Insurance Corp. - Policy #WA5-63D-510199-315; Effective: 4/1/2025-4/1/2026 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Insurance Corp. - Policy #WA7-63D-510199-405; Effective: 4/ 112025-4/1/2026 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Mutual Insurance Corp. - Policy #WC5-631-510199-255 (WI); Effective: 4/1 /2025-4/1 /2026 WORKERS COMPENSATION POLICIES: OHC of Arkansas - Liberty insurance Corp.. - Policy #WC7-631-510199-285; Effective: 4/1/2025-4/112026 OHC of Southwest (AZ/'UT) _ Liberty Mutual Fire Insurance Company- Policy #WC2-631-510199-245; Effective: 411/2025-4/1/2026 OHC of Delaware - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199M335; Effective: 41V20254/ /2026 OHC of Georgia/Hawaii Liberty Mutr aN Fire Insurance Company - Policy #WC2-631-510199-385; Effective. 411/2025-411/2026 OHC of Illinois -Liberty Mutual F1rca Insurance Company - Policy #WC2-631-510199-415; Effective: 411/2025-4/112026 OHC of Louisiana - Libarty Mutual Fire ifrsurance Company - Policy #WC2-631-510199-295; Effective° 4/1120254/V2026 OHC of Michiigan -Liberty Mutual Fire Insurance Company -Policy #WWC2-631. 10199-275; Effective 4/1!'202541112026 OHC of Nebraska -Liberty Maztuat Flre Insurance Company - Policy #WC2-631-510199.375; Effective: 4/1/2025-4/V2026 OHC of New tBrscy -Liberty Mutuap Flre Nllsurance Company - Policy #WC2-631-510199-265, Effective:. 4/112025-411/2026 OHC of North Carolina Liberty Insuurance Corp, -Policy #WWC7-631-510199-345; Effective: 411/2025-4/112026 OHC of southwest (KS) -Liberty Mutual Fire tnsurance Company - Policy #WC2-631-510199-42a; Effective 4/1/20254/112026 Therapy Centers of Southwest IPA (OR) L"uberty Mutual Fire Insurance Company - Policy #WC2-631-510199.395; Effective: 4/V20254/1/2026 Therapy Centers of South Carolina, PA - Liberty Mutual Fire Insurance Company . Policy #WC2-631-510199-305; Effective: 4/V202541112026 OHC of Minnesota -Liberty Mutual Fire Insurance Compan - Policy #WC2'-631-510199-455; Effective: 4/112025.4/1/2026 OHC of Alaska - Liberty Mutual Fire Insurance Company - olicy #WC2-631-510199-445, Effective. 4/112025-4/112026 CYBER LIABILITY - Arch Specialty Insurance Company - Policy #NPL2001106-00; Effective: 11/25/2024-11/25/2025 - Limit: $10,000,000 EXCESS CYBER LIABILITY - Homeland Insurance Company of New York - Policy #720002431-0000; Effective: 11/25/2024-11/25/2025 - Limit: $10,000,000 Excess of $10,000,000 CRIME COVERAGE - National Union Fire Insurance Company of Pittsburgh, PA - Policy #02-173-18-50, Effective 11/25/2024-1/1/2026 - Limit $10,000,000 Coverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured, but only for professional services performed for or on behalf of the above Named Insured. RE: 390 North Sepulveda Blvd, El Segundo, CA OHC CA/CMC has an agreement under contract # 5856 to provide medical services to the employees of the named client. ity of El Segundo, CA; its officials, employees and or agents are additional insureds on the above General Liability, Auto Liability and Umbrella Liability Policies required by written contract. overage provided to the additional insureds shall apply on a Primary / Non -Contributory Basis on the above General Liability, Auto Liability and Umbrella ability policies if required by written contract. dor to loss„ and if recuked by written contract, Waiver` of Subrogation is provided on General Liability, Auto Liability, Umbrella Liability and Workers ompensation Policies for worst performed under contract if permissible by state law. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD