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PROOF OF INSURANCE (2017) CLOSED=DATE DIYYYY) CERTIFICATE OF LIABILITY INSURANCE 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"'" "' Michelle Goodwin.„ CIC, CISR, CPSR InterWest Insurance Services PHONE FAX LAIC,No.Ext).831 635 -2247 __ ____ (AaC.,NQJ.831638 -6801 License #OB01 094 __ 222 Court Street EMAIL i-ngoodwin@iwins.com ADDLtSS 3 _.__.. Woodland CA 95695 INBURERtS) AFFORDING COVERAGE NAIL # .... ..... ........ ......... INSURER Insurance Corporation 42404 -.._ �_._ ....._ _.._... ..._... _. .--- — ..,...._.._ _ INSURED USHE.... A -1 INSURER B:Liberty Mutual Fire Ins Co 23035 U.S. Healthworks, Inc. - - -.... __ ...... _... - -- - - - -. INSURERC.__Safety National Casualty Corp 15105 25124 Springfield Ct., Ste 270 - - -- - - - -- ..... - - -- ............... Valencia CA 91355 ..INSURER D:_ [INSURER E: - INSURERF:__ COVERAGES CERTIFICATE NUMBER 841160320 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. --- - - - - -- -- - - - - -- ......... ADDL UBR INSR TYPE OF INSURANCE LTR IN D WVO POLICY NUMBER POLICY EFF POLICY EXP LIMITS MMIDD/YYYY MMIDDIYYYY B X COMMERCIAL GENERAL LIABILITY Y TB2691450294036 9/1/2016 9/1/2017 EACH OCCURRENCE $1,000,000 - TSAVL 1 J CLAIMS -MADE 111 OCCUR PRENWISES,(Eaaccurrence)„ $1,000,000 ..... - -- . '.. MED EXP (Any one person) $ 10,000 _...GEN'L ... PERSONAL &ADVINJURY �AGGREGATE $1,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL. $ ,000,000 POLICY ❑ JEC1 LOC PRODUCTS - COMP /OPAGG,,,,,,,, �.. $2.000,000 OTHER: $ B AUTOMOBILE LIABILITY AS2691450294045 9/1/2016 9/1/2017 � COMBINED SINGLE ' $1 000 000 X ANY AUTO BODILY INJURY (Per person) $ ................ ALL OWNED SCHEDULED _ ._._..... _.___._._ ._..._ BODILY INJURY (Per accident) _..._ $ ............... ............ NON -OWNED X X PRtiSi�l7 "Y bA.tirNA�,;C. $ HIRED AUTOS AUTOS - (`Parccdwaeu�ly A X UMBRELLA LIAB X OCCUR TH7691450294056 91l/2016 9/1/2017 EACH OCCURRENCE $25,000,000 -- AGGREGATE - . .................. $25,000,000 .............. EXCESS LIAB CLAIMS -MADE ........ _._ $ DED...,.X..... RET ENTION $10.. 000 C WORKERS COMPENSATION LDC4042721 9/1/2016 9/1/2017 OT X STATUTE ER A ND EMPLOYERS' LIABILITY YIN I ANY PROPRIETOR /PARTNER /EXECUTIVE E L EACH ACCIDENT $2,000,000 OFFICEWMEMBER EXCLUDED? NIA , m.. ,........ ................ _.. ..., ..__............_.. (Mandatory in NH) E L, DISEASE EA EMPLOYEE I $2,000.000 If ......._.,,,,,,, DESCRIPTION OF OPERATIONS below Ll E L DISEASE POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES ACORD 101,Additional Remarks Schedule, maybe attached If more space is required) Re: 390 North Sepulveda Blvd, El Segundo, CA Certificate holder is included as additional insured when required by written contract per the attached endorsements. CERTIFICATE HOLDER CANCELLATION '10 days notice for non pay('nent. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo, its officials, employees THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street, Room 5 ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo CA 90245 -3813 AUTHORIZED REPRESENTATIVE y„ ©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 INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: C OMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Required By Written Contract Information required to Location(s) Of Covered Operations Required By Written Contract if not shown above.. will be 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 work" out of which the Injury or damage arlses 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 9/11/116 For attachment to Policy No. TB 2 6 91 4 5 0 2 9 4 0 3 6 Audit Basis 0 ISO Properties, Inc., 2004 CG 2010 07 04 ACC>R ► CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) •-" 4/28/2016 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 Michelle In CIC CISFt„ CPSA InterWest Insurance Services { v " r ` F�tX PHONE N•.Et). 163 2247 tic Nil. 6831638 -6801 License #0601094 222 Court Streettss: OF INSURANCE mgoodwon�iwlns.com Woodland CA 95695 ISSUED TO THE INSURED INSURER(S) AFFORDING COVERAGE NAIC p wsURERA :NORCAL Mutual Ins Company ------- 33200 INSURED USHEA -1 CERTIFICATE MAY BE ISSUED OR MAY INSURER B: U.S. Healthworks, Inc. THE POLICIES DESCRIBED INSURERC: EXCLUSIONS AND CONDITIONS OF SUCH 25124 Springfield Ct., Ste 200 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Valencia CA 91355 YNSR ... .. .. .. ............. . -. --- INSURER D SUBR� ..,.. POLICY EFF T POLICY EXP INSURER E : LTR TYPE OF INSURANCE COVERAGES CERTIFICATE NUMBER; 510447744 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. YNSR ... .. .. .. ............. . -. --- ADDL SUBR� ..,.. POLICY EFF T POLICY EXP LTR TYPE OF INSURANCE IN POLICY NUMBER MMIDDIYYYY ` MMIODNYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ _bAMAGFTGRENTEU -_ ., CLAIMS -MADE I OCCUR PREMI.$ES.(Eaoccurrence) ,._$ -------------- MED EXP (Any one person) $ PERSONAL & ADV INJURY $ PEN °L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY LOC 'PRODUCTS-COMP OP AGG $ OTHER: $ AUTOMOBILE LIABILITY $ �Ea accident,] _ _ ANY AUTO BODILY INJURY (Per person) $ ....... AUTOS OWNED .......... SCHEDULED AUTOS BODILY INJURY (Per accident) $ NON -OWNED .. i�Y201�E�rY"" bArvhAGE ... ....................... .... $ HIREDAUTOS AUTOS tFeraccidenti UMBRELLA LIAR'., OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $• DED : RETENTION 8 $ _ WORKERS COMPENSATION OOH �,SI8T�ITE, I AND EMPLOYERS' LIABILITY YIN .,,, .•,I, ANY PROPRIETOR/PARTNER/EXECUTIVE """M""7 OFFICER/MEMBER EXCLUDED �' �I, NIA • •$ •• (Mandatory E. L �D SEASECEDA EMPLOYEE' If yes, describe under ,...... .................. .............. .. ..... DESCRIPTION OF OPERATIONS below E . DISEASE - POLICY LIMIT $ A Medical Malpractice 721820E 5/1/2016 5/112017 Aggregate $3,000,000 A Professional Liability 721823N 5/1/2016 5/1/2017 Limit $1,000,000 $150,000 Ded IUCA/TX/FLIWA Ded, -All Other States $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mole space is required) Although multiple policies are shown above, the person or organization identified above as the Insured qualifies as an Insured under only one of those policies shown, and the coverages and limits of liability for such coverages of only one of those policies will apply to that Insured. Loc #14063001 , LAX CERTIFICATE HOLDER CANCELLATION 10 Gays for Non Payment of Premium SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 14063001 U. S. HealthWorks, Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 390 N. Sepulveda, Suite 1000 ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo CA 90245 AUTHORIZED REPRESENTATIVE p e r 1988 -2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD