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PROOF OF INSURANCE (2009) CLOSED (2)ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE (MM / PRODUCER 9/1/2009 4/28/22009 009 Y) LOCKTON COMPANIES, LLC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 5847 SAN FELIPE, SUITE 320 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOUSTON TX 77057 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 866 - 260 -3538 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. JINRERS AFFORDING COVERAGE NAIC # INSURED U.S. 4 SPRINGFIELD INC. 1309356 25124 SPRINGFIELD COURT, SUITE 200 : Liberty MuP rance Company 23035 VALENCIA CA 91355 : Hartford Cnce Company 29424 The Doctors Interinsurance Exchange 34495 SL Paul Fire urance Company 24767 COVERAGES Nj THIS RERTIFICATE OF INSUROT CONSTrl I I M A CCONTRACT BEETWEEN THE ISSUING THE POL ICIES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L EFECTIVE LTR INSRD TYPE OF INSURANCE POLICY NUMBER POLICY DATE (MM %DD/YY) PDATE ( M EXIRATIO %DD/Y )) N GENERAL LIABILITY LIMITS EACH OCCURRENCE $ 1,000,000 B X COMMERCIAL GENERAL LIABILITY 61UENHY9296 9 /l /G008 9/1/2009 DAMAGE TO RENTED PREMISES Ea occurence $ 300 000 CLAIMS MADE X OCCUR MED EXP (Any one person) - $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- PRODUCTS - COMP /OP AGG $ 3,000,000 POLICY JECT X LOC A AUTOMOBILE LIABILITY AS2 -691- 450294 -028 9/1/2008 9/1/2009 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ XXXXXXX X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) $ XXXXXXX PROPERTY DAMAGE (Per accident) $ XXXXXXX GARAGE LIABILITY NOT APPLICABLE AUTO ONLY - EA ACCIDENT $ XXXXXXX ANY AUTO OTHER THAN EA ACC $ XXXXXXX AUTO ONLY AGG $ XXXXXXX EXCESS/UMBRELLA LIABILITY D X OCCUR EI CLAIMS MADE QK09101382 9/1/2008 9/1/2009 EACH OCCURRENCE $ 15 000'000 AGGREGATE $ 15 000000 UMBRELLA $ XXXXXXX DEDUCTIBLE FORM X RETENTION $ L0,000 $ XXXXXXX ,000 $ XXXXXXX A WORKERS COMPENSATION AND WA2 -69D- 450294 -018 9/1/2008 9/1/2009 WC STATU- OT EMPLOYERS' LIABILITY X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? It yes, describe under E.L. DISEASE - EA EMPLOYEE $ 1,000,000 SPECIAL PROVISIONS below No C OTHER E.L. DISEASE - POLICY LIMIT $ 1,000,000 0069727 5/1/2009 5/1/2010 $I,000,000 Per Claim Medical Professional $3,000,000 Annual Aggregate Liability: Claims Made Deductible: $100,000 Per Claim DESCRIPTION OF OPERATIONS /LOCATIONSIVEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS ADDITIONAL INSURED IN FAVOR OF CITY OF EL SEGUNDO, ITS OFFICIALS, AND EMPLOYEES (ON ALL POLICIES EXCEPT WORKERS' COMPENSATION /EL AND MEDICAL PROFESSIONAL LIABILITY) WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION [D449739) F____TO_44404181 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF EL SEGUNDO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 350 MAIN STREET EL SEGUNDO CA 90245 381 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATI ACORD 25 (2001/08) For questions regarding this certificate, contact the number listed in the'Producer4 section above. ©AC D CORPORATInN 1 QRR DA ) AGO OF LIABILITY INSURANCE PRODUCER LOCKTON COMPANIES, LLC 5847 SAN FELIPE, SUITE 320 9/1/2010 8i28�20 s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO HOUSTON TX 77057 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA7 HOLDER. THIS CERTIFICATE DOES NOT AMEND, 866- 260 -3538 EXTEND C ALTER THE COVERAGE AFFORDED BY THE POLICIES BEL04 INSURED U.S. HEALTHWORKS INC. INSURERS AFFORDING COVERAGE NAIC # 1309327 25124 SPRINGFIELD COURT, SUITE 200 INSURER A: Liberty Mutual Fire Insurance Company 23035 VALENCIA CA 91355 INSURER B: Hartford Casualty Insurance Company 29424 X INSURER C: St Paul Fire and Marine Insurance Co 24767 $ XXXXXXX INSURER 0: INSURER E COVERAGES NL THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRAC ' BETWEEN THE ISSUING 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR tNSRD TYPE OF INSURANCE POLICY NUMBER PATE MM/Op/YY DATE (MMIDD1YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1.000.0w) B X COMMERCIAL GENERAL LIABILITY 61 UENHY9296 DAMA TO RENTED 9/1/2009 9/1/2010 aoccuren $ 300000 CLAIMS MADE 1 OCCUR MEO EXP (Any one person) $ 10000 GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL & ADV INJURY $ 1 .000.000 I PRODUCTS - COMPIOP AGG 1 $ 3_000_nnn A AUTOMOBILE X LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON -OWNED AUTOS AS2 -691- 450294 -029 9/1/2009 9/1/2010 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ j{}{}{�{} jt X BODILY INJURY (Per accident) $ XXXXXXX X PROPERTY DAMAGE (Per accident) $ XXXXXXX fGARAGE LIABILITY Y auTD NOT APPLICABLE AUTO ONLY - EA ACCIDENT $ XXXXXXX OTHER THAN EA ACC AUTO ONLY: AGG $ XXXXXXX $ XXXXXXX C A IUMBRELLA LIABILITY CUR a CLAIMS MADE UMBRELLA DEDUCTIBLE � FORM RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPMETORIPARTNER/EXECUTIVE OFFICEMMEMBER EXCLUDED? If res. describe under SPECIAL PROVISIONS below NO OTHER QK09I01752 WA2- 69D450294 -019 9/1/2009 911/2009 9/1/2010 9/1/2010 EACH OCCURRENCE $ 20 000 DOO AGGREGATE $ 20,0- 0- 0 OOO $ XXXXXXX $ XXXXXXX WCSTATU- OTH- X T RY LIMI $ XXXXXXX E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E. L. DISEASE - POLICY LIMIT $ 1,000,000 Re: Evidence of Insurance U.S. Healthworks, Inc. 309 LAX / Attn: Center Manager l 390 N. Sepulveda, Suite 1000 EI Segundo CA 90245 ACORD 25 (3001/08) For quealons regarding this SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATI POLICY NUMBER: COMMERCIAL GENERAL LIABILITY 61 UENHY9296 CG 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.10 07 04 ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Ornanizationlst- Blanket where required in a written contract. Information required to complete this Schedule, if not shown Of Covered will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 Attachment Code : D449739 Certificate ID : 10440481 © ISO Properties, Inc., 2004