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PROOF OF INSURANCE (2014) CLOSED"' CERTIFICATE OF LIABILITY' INS NCE [–DATE 2oD .3' PRODUCER (800) 955 -5578 FAX: (800) 530 -5725 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Palos Verdes Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 314 Vista Del Mar, PO Box 636 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Redondo Beach CA 90277 -0636 INSURERS AFFORDING COVERAGE NAIC # INSURED INsuRERAGolden Eagle Insurance Carp Westchester Medical Group INSURER B: 360 N. Sepulveda Blvd #3000 INSURER C: E1 Segundo CA 90245 INSURERS COVERAGES 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 WIIITH 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 OISUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN R. DD woo nc iusnaeNCF POLICY NUMBER P(SLICY dF V EXPI •. LIMrrS GENERAL LIABILITY EARCHIOSCCUa+1_ s 2,000,000 X COMMERCIAL GENERAL LIABILITY _ s 100.000 MED EXP IArn one Gerson) S 51000 A X CLAIMS MADE OCCUR DP1079676 1/2/2013 1/2/2014 SONALBADWINJURY PER , rv� S 200.000 GFNFRAL AGGREGATE S PRODUCTS- COMPIOPAGG S 4.000 000 GEVL AGGREGATE LIMIT APPLIES PER: IT X POLICY I PR' LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 ANY AUTO Ea accident) ALL OVMED AUTOS BODILY INJURY $ SCHEDULED AUTOS MP1079676 1/2/2013 1/2/2014 (Perpe —) A X HIRED AUTOS BODILY INJURY $ (Par accident) X NON- OWNEDAUTOS PROPERTY DAMAGE $ (Per accidenq GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S ANY AUTO OTHERTHAN EAACC $ S AUTO ONLY: AGG EXCESSIUMSRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE S f DEDUCTIBLE RETENTION $ f WORKERS COMPENSATION j Tn.STA,' • OTR AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT f OFFICEROMEUSER EXCLUDED? ❑ dMand'eier)p' III NN) E,L DISEASE - EA EMPLOYE ; E.L. DISEASE - POLICY LIMIT S S�ras tlaacriSe 11Alt!AI PRO INS below OTHER DESCmFrnON OF OPERATIONS I LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS iThe Certificate holder is hereby named as additional insured with respects to general liability per form #GECG602 (O1 /11) Page 4 of 4 Paragraph B CERTIFICATE HOLDER - -- _ CANCELLATION SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL )Si3i "MAIL 30 DAYS WRITTEN City of E1 Segundo, Officials and NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Employees � Attn: Administration Services 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 Denise Sutter /DEN D 25 (2009109) 01988.200'9 ACORD CORPORATION, All rights reserved. (200901).01 The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 IN5025 (200901).01 COOPERATIVE VE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coverage through December 31, 2013 Member: Allen Pachtman, MD Address: 360 N. Sepulveda Blvd., #3000 El Segundo, CA 90245 This certificate confirms that, on the date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement. Membership Number Medical Specialty Coverage Date Retroactive Coverage Date 5908 Internal Medicine September 1, 1990 January 1, 1986 Subspecialty Coverage (Claims made and paid) Current Limits of Liability $1,000,000 for all Claims based Medical Professional Liability Coverage upon an Occurrence $3,000,000 each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage. Claims History No Claims Reported The Claims history listed above includes all Claims that are currently open and those that were closed within the last five years The Claims history also includes payments for emergency or other remedial expenses that exceed $30,000 that were made to patients through MPT's Patient Assistance Services program. Cooperative of American Physicians, Inc. January 15, 2013 Hammon P. Acuna Date Vice President, Membership Services Mutual Protection Trust 151 COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coverage through December 31, 2013 Member: Robert A. Reiss, MD Address: 360 N Sepulveda Blvd Ste 3000 EI Segundo, CA 90245 This certificate confirms that, on the date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement. Membership Number 5906 Medical Specialty Internal Medicine Coverage Date September 1, 1990 Retroactive Coverage Date January 1, 1986 Subspecialty Sports Medicine, Primary Care Coverage (Claims made and paid) Current Limits of Liability $1,000,000 for all Claims based Medical Professional Liability Coverage upon an Occurrence $3,000,000 each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage. Claims History No Claims Reported The Claims history listed above includes all Claims that are currently open and those that were closed within the last five years The Claims history also includes payments for emergency or other remedial expenses that exceed $30,000 that were made to patients through MPT's Patient Assistance Services program. Cooperative of American Physicians, Inc. January 15, 2013 Hammon P. Acuna Date Vice President, Membership Services Mutual Protection Trust ONCE) COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coverage thivugh December 31, 2013 Member: David M. Weiss, MD Address: 360 N Sepulveda Blvd Ste 3000 El Segundo, CA 90245 This certificate confirms that, on the date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement. Membership Number 8525 Medical Specialty Internal Medicine Coverage Date November 1, 1997 Retroactive Coverage Date None Subspecialty Coverage (Claims made and paid) Current Limits of Liability $1,000,000 for all Claims based Medical Professional Liability Covet-age upon an Occurrence $3,000,000 each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, ofany changes to or termination of this coverage. Claims History No Claims Reported The Claims history listed above includes all Claims that are currently open and those that were closed within the last five years The Claims history also includes payments for emergency or other remedial expenses that exceed $30,000 that were made to patients through MPT's Patient Assistance Services program. Cooperative of American Physicians, Inc. -Fr-t- — January 15, 2013 Hammon P. Acuna Date Vice President, Membership Services Mutual Protection Trust 40 J DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 7/252013 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 NNA N.0 Shannon Bailey Michael Ehrenfeld Company PHONE .. -9990 FA "C N.,LAU IA NM(619) 603 -9999 2655 Camino Del Rio North E "AI FL . shannonb@ehrenfeldinsurance.com #200 INSURERISI AFFORDING COVERAGE NAIC # San Diego CA 92108 INSURERA - Preferred EmAlovers Insurance 10900 INSURED Westchester Medical Group INSURER C: 360 N. Sepulveda Blvd INSURER D: Suite 3000 INSURER E: El Segundo CA 90245 INSURER F: COVERAGES CERTIFICATE N'UMBER:13 -14 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. TN ­SR _ ''.ADDL "UIiR ............ . ...... .............. POLICY EFF POLICY EXP Ta TYPE OF INSURANCE Fe � POLICY NUMBER IMM /o0/ w 1 IMMIO ❑ /VVVVI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DA AV R N E ,1 COMMERCIAL GENERAL LIABILITY PRFMICFC rFa ocr�irraoruca.m..._mmBmmIT - m, CLAIMS -MADE �� OCCUR MED EXP (Anv one oersonl S PERSONAL & ADV INJURY $ GENERAL AGGREGATE '..$ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ .„ POLICY PRL " LOC .� AUTOMOBILE LIABILITY dw� JMUBM�L:R:'P IWJG3LE tlwlMl'd' Irn IP i.P l � ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ TS AUTOS NON -OWNED I.®... �- i'"ROPLR TY UAMAGC�:.. HIRED AUTOS.... .. AUTOS �p2_ _ +`�,:_.�u $.... UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS -MADE AGGREGATE $.... DED RETENTION $ $ A WORKERS COMPENSATION X TIATU— OTR AND EMPLOYERS' LIABILITY Y / N T RV - -,.,., _».AI+_.,. -«:.« _. .,.- ..�,�........, -. ANY PROPRIETOR /PARTNER /EXECUTIVE E EACH ACCI DENT $ is 000;, 000' OFFICER /MEMBER EXCLUDED? ❑ (Myyandatory in NH) NIA M N1410624 8/1/2013 8/1/2014 •• °�° °�1 E DISEASE - EA EMPLOYE • ° --- 0 '-° 0 '._$ 1.000.000 _ - )... DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of E1 Segundo City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. Admin Services Director 350 Main Street Room 5 AUTHORIZED REPRESENTATIVE E1 Segundo, CA 90245 -3813 Gabe Erle /SB ACORD 25 (2010/05) © 1988 -2010 ACORD CORPORATION. All rights reserved. INS025 (201005) 01 The ACORD name and logo are registered marks of ACORD