PROOF OF INSURANCE (2016) CLOSEDACORP,, CERTIFILATE OF LIABILITY INSUr &A 11CS DATE(MMft)DNM)
06/19/2015
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.
M the certificate o de'r Is an WITIORAL INJURE6, I. o po icy les must bd en Uorsed. If SU'BR ATIO 1, AI i), su act 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
N E.
Hodgkiss Insurance Brokers It_
NsdA�.� At 626.285.2785
License #0651915 626.703 4350 c,Ne
ADDRESS:
2275
�w._._ .. ® .. _ ®. _ _ ... - -- -
2275 Huntington Drive Ste 271 INST!_RTj�' FORDING COVERAGE NAIC0
Ian Marino, 91108-2640 tndmark American insurance
INSURED V tai" Medi ca 5ery a "LLC INSURER B, S ate WSq a at onnIns Fund 35076IT
550 N. Brand Blvd., Ste. 600 INSURER .._.... . �.�.a� . ............ . ...._ . , ..... .M .. �.� n. _.
INSURES c
Glendale, CA 91203 _�.,0: ,. �mm.,.,
INSURER D
INSURER E
... ..
INSURER F:
COVERAGES CERTIFICATE NUMBED: 1$/16 Landmark REVISION NUMBER:
INDICATED. NOTWITHSTANDING ANY REQUIIREMEN'T, TERM OR CONDITION F ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
HICH 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,
.._ .. ...,, ... wVe POLICY NU . -. p�q
BR. ��MY L7�Si
R TYPE OF INSURANCE „
I�ls . _ NUMBER MMICI MMiDDI'YY"YY' LIMITS
GENERAL LIABILITY LHC82690 06/18/2015 08/18/2018 EACH OCCURRENCE s 1.000.00
DDIIA REETrTrE�a_... _.._
X COIAMERCIAL GENEIIAL IAIAEkILITY PREMISES IEz acorrrrer+rl4 i 50.00
_ CLAIMS ADE OCCUR MED EXP (Arty one person) S 5 (j
PERSONALS 11 __�
A X $2 , 500 Deductible X ADV INJURY s 1.000.00
._.....A .., —C, .._._.... GENERAL AGGREGATE �� , ".�.. .
BI /PD Comb %Per Occ �µ"`""°"""
... ... 3.000.00
0 AGG S 1.000
/O
- COMP/OP .
GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS 00
X POLICY
PFD T LOC S
AUTOMOBILE LIABILITY
ANY AUTO BODILY INJURY (Per person) S
ALL OWNED SCHEDULED BODILY INJURY Perm __
HIRED AUTOS AUTOS enq S
AUTOS AUTOS
NON -OWNED
"P $
Ir 1Ir�cldanrt
UMBRELLALIAB OCCUR EACH OCCURRENCE S
EXCESSLUB
.. CLAIMS-MADE
AGGR, EGATE
_ $
DED RETENTIONS
S ...�
WORKERS COMAPENSATION 9116288 -I 10128/2014 1012812015 X OC
AND EMPLOYERS'LIABILITY YIN RYLIM B ON
ANY FIdE E E C D? ECUTIV NIA E L EACH ACCIDENTIT FR $ 1.000.000
Ir as descnhe under E.L. DlsEas EMPLOYEE s 1 000.00
$1,000,000 E . EA EMPLO .. _..,. . 0
LHC82696 06/1812015 06/18/2018
U RIPTION Of OPERATIONS bslBww E.L. DISEASE MIT S 1,000,000
E - POLICY LI
OF 55 A9 LITY Per Claim
A
laims Made -Retro Date $3,000,000 Aggregate
.:11/20/12
$2,500 Deductible
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 141, Additional Remarks Schedule, H more space Is required)
ity of El Segundo Police Deparment, its officials and employees are named additional insured as
espects work usual to the named insured provided to the certificate holder, and coverage is primary
is required by written contract, per provisions of RSG MANUSCRIPT form attached to policy. Waiver of
abrogation also applies to Workers' Compensation.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
City of E1 Segundo Police Deparment
Attn: Lt. Jeff Leyman AUTHORIEDREPR'ES'NTATIVE
350 Main St. t
El ,Segundo, CA 90245
1988 010 ORGY CORPORATION, All rig
ACORD 25 (2010105) The ACORD name and logo are registered marks Df D
This Endorsement Changes The Policy. Please Read It Carefully
ADDITIONAL INSURED BLANKET - PRIMARY NON-
CONTRIBUTORY WORDING WITH WAVIER OF SUBROGATION
This endorsement modifies insurance provided under the following:
SCHEDULE
Name of Person or Organization: .� a. person ......_.
.. written g y erson or organization to whom or to which you are obligated by virtue
contract or by the issuance or existence of a written permit, to
provide insurance such as is afforded this policy_
A. SECTION II - WHO IS AN INSURED is amended to include as an additional insured the person(s) or
organization(s) shown on 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:
1. 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 insured, 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.
If you are required by a written contract to provide primary insurance, this policy shall be primary and non-
contributory as respects to your negligence and SECTION IV — COMMERCIAL GENERAL LIABILITY
CONDITIONS, 4. Other Insurance does not apply, but only with respect to coverage provided by this policy.
Furthermore, it is also agreed that the following is added to SECTION IV — CONDITIONS, 8. TRANSFER
OF RIGHTS OF RECOVERY AGAINST OTHER TO US:
We waive any right of recovery we may have against the person or organization shown in the SCHEDULE
above because of payment we make for injury or damage arising out of your ongoing operations, "your
product" or "your work" done under a written contract with that person or organization and included in the
"product- completed operations hazard ". This waiver applies only to the person or organization shown in
the SCHEDULE above.
All other terms, conditions and warranties remaining unchanged
This endorsement effective
forms part of Policy Number LHC826907
issued to Endorsement No.:
by: Date Processed
MANUSCRIPT
HOME OFFICE
SAN FRANCISCO
ALL EFFECTIVE DATES ARE
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
ENDORSEMENT AGREEMENT BROKER COPY
WAIVER OF SUBROGATION
BLANKET BASIS 9116288 -14
NEW
SC
EFFECTIVE OCTOBER 28, 2014 AT 12.01 A.M. PAGE 1 OF 1
AND EXPIRING OCTOBER 28, 2015 AT 12.01 A.M.
VITAL MEDICAL SERVICES, LLC
550 N. BRAND BLVD., STE. 600
GLENDALE, CA 91204
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.
THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE
2.00% OF THE TOTAL POLICY PREMIUM.
SCHEDULE
PERSON OR ORGANIZATION JOB DESCRIPTION
ANY PERSON OR ORGANIZATION BLANKET WAIVER OF
FOR WHOM THE NAMED INSURED SUBROGATION
HAS AGREED BY WRITTEN
CONTRACT TO FURNISH THIS
WAIVER
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: OCTOBER 31, 20114
AUTHORIZED REPRESENT IVE PRESIDENT AND CEO
SCIF FORM 10217 IREV.7.2014)
2572
OLD OF 217
„ , .,.,
' a
April 16, 2015
Angelina Garcia
City of El Segundo Police Department
348 Main Street
El Segundo, California 90245
Dear Angelina;
I wanted to formally put in writing that Vital Medical Services does not own any company vehicles. All of our
staff currently operates their own vehicles and carries their own vehicle insurance. When responses are
required by our staff, they will not violate local, state and or federal laws pertaining to the response. They
abide by all traffic rules and regulations.
Please let me now if you need any additional documentation pertaining to this topic.
Respectfully,
Alex G. Ghazalpour
Chief Operating Officer
Vital Medical Services