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PROOF OF INSURANCE (2016) CLOSEDAC"FEO CERTIFICATE OF LIABILITY INSURANCE �/6/2O15YY) 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 INSURERA :Golden Eagle insurance Corp Westchester Medical Group INSURER B: 360 N. Sepulveda Blvd #3000 INSURER C: I INSURER D: El Segundo CA 90245 INSURERS COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTAN DING 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, 0.NSR ADD "d.:. T- _..TYKE OF tN.BIRAN4,CE;. ...... P'OLIC'Y NUMBER ...DATE RMMIDDiYYY'�) I DATE POLICY E'XP0.RATk0�1 .... LIMITS POLICY EFFECTIVE GENERAL LAWLITY J EACH OCCURRENCE $ 2, 000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE Tb RENTED $ 100., 000 s P_ X CIARAlP"P+ADE Y OCCUR`BKS56298065 PRFMISFS fFa [x:rurrenr,.a1 01/02/2015 01/02/2016 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 2,000,000 I GENERAL AGGREGATE +$ _ 4,000, 000 G E N'LAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 4, 000,. 000 PRO- LOC X POLICY 1 ..... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT � ANY AUTO") (Ea accident) $ 1,000,000 A4.8 OVdNI IbAUTOS SCHEDULED AUTOS BAS56298065 BODILY INJURY 01/02/2015 � 01/02/2016 (Per person) A X 11111T ED ALL "OS BODILY INJURY �C � 0.!Vd';}N•Q}Yiu'I`vIP'C'bAUG`4�u (Per accident) � � 1 PROPERTY DAMAGE '$ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT !S ` ANY AUTO OTHER THAN EA ACC _$ AUTO ONLY: AGG , S EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE OCCUR CLAIMS MADE I AGGREGATE ;$ DEDUCTIBLE RETENTION '$ ' WORKERS COMPENSATION , -. AND EMPLOYERS' LIABILITY Y / N " T Y L9MII.. (TH -1 ANY PROPRIETOR /PARTNER /EXECUTIVE I E L, EACH ACCIDENT ; $ OFFICER M MBER EXCLUDED t (Mandatory in NH) ` ( E L DISEASE - EA EMPt OYEE1 $ If yes describe under ,Iwf f.IA0. PROVIS1ONS bek)w I; E L DISEASE - POLICY LIMIT $ OTHER 1 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS The Certificate holder is hereby named as additional insured with respects to general liability per form #GECG602 (01 /11) Page 4 of 4 Paragraph B CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL MA XIYMAIL 3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, XKy' %)(IXX9C� XX%XLX City of E1 Segundo, Officials and Employees KAA Attn: Administration Services 350 Main Street E1 Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2009/01) Denise Sutter /VICKIE ` © 1988-2009 ACORD CORPORATION. All rights reserved. INS025 (200901) 01 The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 88 62 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -BLANKET VENDORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Section II - Who Is An Insured is amended to include as an additional insured any person(s) or organiza- tion(s) (referred to throughout this endorsement as vendor) whom you have agreed to add as an additional insured in a written contract or written agreement, but only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these vendors, the following exclusions apply: 1. The insurance afforded the vendor does not apply to: a. "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agree- ment; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, except when unpacked solely for the purpose of inspection, demonstration, test- ing or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; e. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; f. Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or h. "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (1) The exceptions contained in Subparagraphs d. or f.; or (2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. C. This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products. © 2013 Liberty Mutual Insurance CG 88 62 04 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission, Page 1 of 1 `�" CERTIFICATE OF LIABILITY INSURANCE °A�'MM,D° 7/30/2015 15 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 pollcy(les) must be endorsed. It SUBRO ATION 13 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 Ilsu of such endr raornon1w PRODUCER Michael Ehrenfeld Company 2655 Camino Dal Rio North 4200 San Diego CA 92108 INSURED Westchester Medical Group 360 N. Sepulveda Blvd Suite 3000 Bailey Sban tlshaAnonb@ehren' "+Bldinsuran ce corm. (LL619) 683 9999, El Segundo CA 90245 Na .�_� COVERAGES CERTIFICATE NUMBER :15 -16 WC aF. _ REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED D ABOVE FOR THE POLICY PERIOD INDICATED, NOTWTHSTANDING 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. R COMMERCWOFIN ERALLU4BILITY m TYPO OF INSURANCE .,, w P._,.�..,.M _.....w_ .. Lf Mtl7fG ..... POLICY YIIY P,,,. EA �CLAIMS•MAEN 1OCCUR CH OCCURRENCE S MED EXP (Any one person) 0 $ ._. w T W ....y PERSONAL6ADVIN INJURY S GE NL AGGREGATE LIMIT IT APPLIES PER _. POLICY L-1 MR 7 _GENERAL AGGREGATE S _. LOC PRODUCTS . COMP/OP AGG S rHEIr° S AUTOMOBILE LIABILITY LIMT ANY AUTO BODILY INJURY Per ALL WMED ... SCHEDULED - -- _ AUTOS AUTOS BODILY INJURY (Per ecddent) S NON -OVWED H D R AUTOS AUTOS N S i UMBRELLA UAB OCCUR F.ACHOCCRENCE $ EXCESS LIAB ni eiucAAene1 ,_ .. EMPLOYERS' LIABILITY A NIA CAer1410626 8/1/2015 1 8/1/2016 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Addklonal Remarks Schedule, maybe attached If more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo City Clark THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Admin Service$ Director ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street Room 5 E1 Segundo, CA 90245 -3813 AUTHORIZED REPRESENTATIVE Gabe Erle /SB z,,,_96— 1988 -2014 ACORD CORPORATION. All rights reserve ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) E(S) CERTIFICATE OF COVERAGE Coverage through December 31, 2015 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,. Cooperative of American Physicians, Inc. '.^ 4 °.- January 24, 2015 Hammon P. Acuna Date Vice President, Membership Services Mutual Protection Trust CERTIFICATE OF COVERAGE C'overage through December 31, 2015 Member: Robert A. Reiss, 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 12807. 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 i Retroactive Coverage Date 5906 Internal Medicine September 1, 1990 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. Cooperative of American Physicians, Inc. lzp/a 'eq Hammon P, Acuna Date Vice President, Membership Services Mutual Protection Trust January 24, 2015 CERTIFICATE OF COVERAGE C(werage through December 31, 2015 i\ Member: David M. Weiss, MD Q , 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 Medical Specialty Coverage Date Retroactive Coverage Date 8525 Internal Medicine November 1, 1997 None 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, Cooperative of American Physicians, Inc. �— January 24, 2015 Hammon P., Acuna Date Vice President, Membership Services Mutual Protection Trust