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PROOF OF INSURANCE (2014) CLOSEDAgreement No. 4538 Clinical Laboratory of San Bernardino Inc. 10 A+CC>RV CERTIFICATE OF LIABILITY INSURANCE li0 . DATE (MMIDD/YYYY) 12/04/2013 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 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 1- 909 - 243 -8200 CONTACT NAME. PHONE 1 909_- 243 -8200 FAX No:909- 243 -8201 Hays of California Insurance Services - Ontario MAIL ADDRESS: Empire Towers IV PRODUCER _ CUSTOMERJD# c......_._......__.._.......__............__..__.. ------- —____...-....__.... --- _ ------- ..,._.._. .--.....__.- ....i_.___.._...... 3800 Concours, Suite 3400 Ontario, CA 91764 Kelly Peterson INSURER(S)AFFORDINGCOVERAGE INSURED INSURERA Trans ortation Insurance Company Transportation p.....Y.... Clinical Laboratories of San Bernardino, Inc. INSURERB: Transportation insurance Co. i INSURERC: Hartford Fire Insurance Company P.O. Box 329 INSURERD Columbia Casualty Company San Bernardino, CA 92402 INSURER E : _ INSURER F : MED EXP (Any one person) COVERAGES CERTIFICATE NUMBER: 37186921 REVISION NUMBER: 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 LTR I TYPE OF INSURANCE INSR S rVD POLICY NUMBER MWDNYYY MMIDDY� LIMITS A GENERAL LIABILITY X X C 4034939429 02/01/13 02/01/14 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO R NTED PREMISES Ea occunence $ 100,000 CLAIMS -MADE D OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOPAGG $ Excluded $ X POLICY PRO- LOC B AUTOMOBILE LIABILITY X X C 4034939463 02/01/13 02/01/14 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO i BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ _ SCHEDULED AUTOS ---------.....-_......----..---- .... ...... PROPERTY DAMAGE ._ .... .........------........._..-....----...— $ X HIRED AUTOS (Per accident) X NON -OWNED AUTOS $ $ B X UMBRELLA LIAB X OCCUR C 4034939477 02/01/13 02/01/14 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000, 000 EXCESS LIAB CLAIMS -MADE X VCVVV 1164C RETENTION $ 0 $ C WORKERS COMPENSATION X 41WEC BK0213 02/01/13 02/01/14 X TORY LIMITS OER AND EMPLOYERS' LIABILITY YIN E.L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETORIPARTNER/EXECUTIVE t OF EXCLUDED? (Mandatory In NH) N/A ' E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE- POLICY LIMIT $ 1,000,00 If yes, describe under DESCRIPTION OF OPERATIONS below i D Professional Liability 27- 617 -09 -23 - Claims Mae 3 De DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) The City of E1 Segundo, its officials and employees are named Additional Insured as respects work performed by the named insured only. Insurance is primary and non - contributory k;tKI1hIL;Al It HULUtK /'\ I- ,KN%LCLLA11U1V SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. James Turner 4000 Lomita St. :111yPeterson ORIZED RE7YSEN TA TIVE El Segundo, CA 902451Z&i &,tjj for USA , f� ACampos ©1988 2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009 /09) The ACORD name and logo are registered marks of ACORD 37186921 G- 134802 -C CAM (Ed. 11/04) THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ,4 NONCONTRACTOR'S ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: 'r COMMERCIAL GENERAL LIABILITY COVERAGE PART A. WHO IS AN INSURED (Section IQ is amended to include as an Insured any person or organization (called additional insured) described In paragraphs 2.a.through 2.g. below whom you are required to add as an additional Insured on this policy under a written contract or agreement but the written contract or agreement must be: 1. Currently in effect or becoming effective during the term of this policy; or 2. Executed prior to the 'bodily injury,' *property damage' or *personal injury and advertising injury,' but Only the following persons or organizations are additional insureds under this endorsement and coverage provided to such additional insureds is limited as provided herein: a. State or Political Subdivisions A state or political subdivision subject to the following provisions: V s (1) This insurance applies only with respect 9 to the following hazards for which the state or political subdivision has Issued a permit in connection with premises you own, rent, or control and to which this insurance applies: (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, c.ellar entrances rnsI hnlas, driveways, manholes, marquees, hoistaway openings, sidewalk vaults, street banners, or decorations and similar exposures; or (b) The construction, erection, or removal of elevators; or (c) The ownership, maintenance, or use of any elevators covered by this insurance. (2) This insurance applies only with respect to operations performed by you or on your behalf for which the state or political subdivision has issued a permit. This insurance does not apply to 'bodily injury,' 'property damage' or 'personal and advertising Injury' arising out of operations performed for the state or municipality. G- 134802 -C (Ed. 11/04) b. Controlling interest Any persons or organizations with a controlling interest In you but only with respect to their liability arising out of: (1) Their financial control of you; or (2) Premises they own, maintain or control while you lease or occupy these premises. This Insurance does not apply to structural alterations, new construction and demolition operations performed by or for such additional insured. c. Managers or Lessors of Promises A manager or lessor of premises but only with respect to liability arising out of the ownership, maintenance or use of that specific part of the premises leased to you and subject to the following additional exclusions: This insurance does not apply to: (1) Any 'occurrence' which takes place after you cease to be a tenant in that premises; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of such additional insured. d. Mortgagee, Assignee or Receiver A mortgagee, assignee or receiver but only with respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of a premises by you. This insurance does not apply to structural alterations, new construction or demolition operations performed by or for such additional insured. e. owners/Other Interests — Land Is Leased An owner or other interest from whom land has been leased by you but only with respect to liability arising out of the ownership, maintenance or use of that specific part of the land leased to you and subject to the following additional exclusions: This insurance does not apply to: Page 1 of 2 D� (1) Any "occurrence' which takes place after you cease to lease that land; or (2) Structural alterations, new construction or demolition operations performed by or on behalf of such additional insured. f. Co-owner of Insured Premises A co -owner of a :premises co -owned by you and covered under this insurance but only B. with respect to the co- owners liability as co- owner of such premises. g. Lessor of Equipment Any person or organization from whom you lease equipment. Such person or organization are insureds only with respect to their liability for "bodily injury,' 'props damage,' or 'personal and advertising injury caused, in whole or in part by your maintenance, operation or use of equipment leased to you by such person or organization. A person's or organization's status as an Insured under this endorsement ends when their written contract or agreement with you for such leased equipment ends. With respect to the insurance afforded these additional insureds, the following additional exclusions apply: This insurance does not apply. (1) To any *occurrence' which takes place after the equipment lease expires; or Q- 184802 -C (Ed. 11104) 0- 134802 -C (Ed. 11104) (2) To "bodily Injury" or 'property damage" arising out of the sole negligence of such additional insured. Any Insurance provided to an additional Insured designated under paragraphs a. through g. above does not apply to 'bodily Injury' or "property damage' included within the 'products- completedpperations hazard.' As respects the coverage provided under this endorsement, Paragraph 4.b. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is deleted and replaced with the following: 4. Ottw Insurance b. Excess Insurance This Insurance is excess over: Any other insurance naming the additional Insured as and insured whether primary, excess, contingent or on any other basis unless a written contract or agreement specifically requires that this insurance be either primary or primary and noncontributing. Where required by written contract or agreement, we will consider any other insurance maintained by the additional insured for injury or damage covered by this endorsement to be excess and noncontributing with this insurance: Page 2 of 2 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US i This endorsement modifies insurance provided under the following: AV , COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization. ANY PERSON OR ORGANIZATION WITH WHOM YOU AGREE IN WRITING TO WAIVE YOUR RIGHT TO RECOVER AGAINST THEM. YOU MUST AGREE TO THIS WAIVER PRIOR TO THE DATE OF LOSS. Information required to complete this Schedule if not shown above will be shown In the Declarations. The following is added to Paragraph 6. Transfer Of Rights Of Recovery Against Others To Us of Section Iv — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for Injury or g damage arising out of your ongoing operations or 'your work' done under a contract with that person or organization and included in the 'products - completed operations hazard.' This waiver applies only to the person or organization shown in the Schedule above. m CG 24 04 05 09 Copyright, Insurance Services Office, Inc., 2008 Page 1 of 1 POLICY NUMBER: C4034939463 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following,, BUSINESS AUTO COVERAGE FORM � \ GARAGE COVERAGE FORM i1 ,� MOTOR CARRIER COVERAGE FORM p� u TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided In the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 02/01/13 Countersigned By: Named Insured: Clinical Laboratories of San Bernardino, Inc. A. tCuthorized Representative V SCHEDULE Name of Person(s) or Organization(s): Any person or organization whom you are required to add as additional insured on this policy under a written contract or written agreement. You must agree to these contracts prior to the date of loss. See Endt (If no entry appears above, information required to complete this endorsement. will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person nr nroanization aualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 +48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 :wwy THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM�J OTHERS ENDORSEMENT - CALIFORNIA Iq�.(j jJ .`• N 1J '1 V Policy Number: 41 WEC BK0213 Endorsement Number: Effective Date. 02/01/13 Effective hour is the same as stated on the information Page of the policy. Named insured and Address: CLINICAL LABORTORIES OF SAN BERNARDINO, INC. PO BOX 329 SAN BERNARDINO, CA 92402 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be premium otherwise due on such remuneration. SCHEDULE Person or Organization ANY PERSON OR ORGANIZATION ANY FROM WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT FO OBTAIN THIS WAIVER OF RIGHTS FROM-US. 3 % of the California workers' compensation Job Description 91 Countersigned by j A4fhorlzed Representative Form WC 04 03 06 (1) Printed in U.S.A. Policy Expiration Date: 02/01/14