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PROOF OF INSURANCE (2016) CLOSEDaN1. I'9w� DATE(MM /DD/YYYY) d %!A CERTIFICATE OF LIABILITY INSURANCE 8/28/2015 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. 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 C NTACT dwln� CIC CISR. CPSR e Michelle (ao�„ InterWest Insurance Services -3 Fnz PHONE 635 2247 � NQ License #0601094 222 Court Street (nrc,�ad,Ealt) „831 - - --, „831-638-6801 ADDRESS” mgoodwln @twins cam___ Woodland CA 95695 I SURE (ikl AFFOR_IING CgyV GE NAIF .......... ... INSURER A: Liberty Mutual Fire Ins Co 23035 -- - -- INSURED USHEA -1 INSURERS. ty Insurance Corooratlon, 42404 U.S. Healthworks Holding Inc. ---- -- y - D......_ ...................... National Casualty Cor, 15105 25124 Springfield Ct., Ste 270 w _Safety _ Valencia CA 91355 wsuRER D ............ __..... - - - - -- INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER-. 796016768 REVISION NI1MR 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. INSR. ., ., -. ADDL S UBT%, ..... .......-- - ---- ---- -POLICY EFF POLICY EXP .. ....... ..... .......... ........ LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER. IMMInr]/WWI MnnlnnnvvYI LIMITS A X COMMERCIAL GENERAL LIABILITY Y TB2691450294035 9/1/2015 9/1/2016 EACH OCCURRENCE $1,000,000 II--- - - - - - -- ......... CLAIMS -MADE � X I OCCUR R tlSES(Eaaccurrancsj $1,000,000 ED EXP (Any one person) $10 000 - - -- .... PERSONAL & ADV INJURY __$1,000.,000 GEN'L AGGREGATE LIMIT APPLIES PER : GENERAL AGGREGATE $2,000,000 PRO '$'2.0'0'0,000 — POLICY ( l X LOG PRODUCTS - COMP /OP AGG ......... OTHER: $ A AUTOMOBILE LIABILITY AS2691450294045 9/1/2015 9/1/2016 � (Ea aacsdanq� m $1.000,000 ,,,.. X ANY AUTO j BODILY INJURY (Per person) $ ALL OWNEDL SCHEDULED AUTOS AUTOS BODILY INJURY Per a ( cident) $ X NON -OWNED AROPER r"Y� dam ` ... $ HIRED AUTOS AUTOS fPap ac�tdm�earrR� , B X UMBRELLA LIAR X OCCUR TH7691450294055 9/1/2015 9/1/2016 7 EACH OCCURRENCE $25,000,000 EXCESS LIAB CLAIMS MADE''.. AGGREGATE $25,000,000 DEL K RETENTION C WORKERS COMPENSATION LDC4042721 9/1/2015 9/1/2016 PER OTH- AND EMPLOYERS' LIABILITY YIN '.... _X STnTl_ITF ER ANY PROPRIETORIPARTNERIEXECUTIVE E, L,. EACH ACCIDENT $2.000.000 OFFICER/MEMBER EXCLUDED? �, NIA "'— ----_- - ..... °.- .......... (Mandatory in NH) E,L, DISEASE - EA EMPLOYE $2.000.000 If yes, describe under .- - ------ -- - -... ,.,., DESCRIPTION OF OPERATIONS below E, L.. DISEASE - POLICY LIMIT $2.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is included as additional insured as required by written contract per the attached endorsement Re: 390 North Sepulveda Blvd, El Segundo, CA CERTIFICATE HOLDER CANCELLATION "10 days notice for non SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo, Its officials, employees(„ , ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street, Room 5 El Segundo CA 90245 -3813 AUTHORIZED REPRESENTATIVE 4w � _ ,P © 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL AL IINSUREI - OWNERS, LESSEES O CONTRACTORS - SCHEDULED PERSON O . ORGANIZATION This endorsement modifies insurance provided under the following: C OMMERCIAL GENERAL LIABILITY COVERAGE PART, SCHEDULE Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Oraanization(s): s Required By Written Contract As Required By Written Contract Information required to complete this Schedule, if not shown above. 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: 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) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on be- half of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your workout of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. This endorsement is executed by the Premium N/A Effective Date 09101115 -16 For attachment to Policy No. TB2691450294035 Audit Basis 0 ISO Properties, Inc., 2004 CG 20 10 07 04 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 7/14/2015 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. 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 PRODUCER nterWest Insurance Services - icense #01301094 22 Court Street Noodland CA 95695 INSURED USHEA -1 U.S. Healthworks Holding Company, Inc. 25124 Springfield Ct., Ste 200 Valencia CA 91355 NX "" Michelle Go dlrll,_C,I, G(Si , CPSR PHONE N F. +,. 831- 635 2247 I;o EMAi m000dwini'ciwins.com The Doctors NG COVERAGE CnVFRAr,PR rr-RTIFIr`.AT mi IMIFt Fi• 1997935231 10MAQ11nid nrr rrilr19=0a 6831 - 638 -6801 NAIC N 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. irLTR TYPE OF INSURANCE 1111..... � 1111..... - ..w... , ,. D 1111 _".".,..r .. . ... 1111 RANCE ki n �wvn POLICY NUMBER M, IDWYy'FYPy MP(M71f0Drr(YY+, LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1111 .. CLAIMS -MADE n °I OCCUR PREMISES raggwEwPa) MED EXP (Any one person) .....s... ... $ ........... 1111... ...._ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE PRdO- ... ....... 1111.. _._. POLICY LOC )E 'q° PRODUCTS COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINI-D SINGLE LEp 9!;90en0, -- 1111. $ --------------- ..------- ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED .....0 -----_._._ BODILY INJURY (Peraccidenl) ................ .. ,. $ NON -OWNED 1111... . HIRED AUTOS AUTOS '..� (Pe�raccgdan� 1111..._ $ ...,,....... $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTIONS WORKERS COMPENSATION f ER OTH- AND EMPLOYERS' LIABILITY YIN CTK ITF ER __ " " "' " "°` 1111. 1111. .---,. ANY PROPRIETOR/PARTNER /EXECUTIVE ELI EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? NIA " "... •1.1.11 (Mandatory in NH) E L DISEASE EA EMPLOYEE $ If yes, describe under 1111.. 1111° .... .. ............ .. ..................... --- ... . DESCRIPTION OF OPERATIONS below E,L. DISEASE - POLICY LIMIT $ A Medical Malpractice 0069727 5/1/2015 5/1/2016 Aggregate $3,000,000 Professional Liability Limit $1,000,000 Deductible $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: 390 North Sepulveda Blvd., El Segundo, CA CERTIFICATE HOLDER City of El Segundo 350 Main Street, Room 5 El Segundo CA 90245 -3813 CANCELLATION 10 Days for Non Pavement of Premium SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD