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PROOF OF INSURANCE (2017) CLOSEDDATE (MMIDD/YYYY}
CERTIFICATE OF LIABILITY INSURANCE 1 12,/1/2015
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,
IM'PORT'ANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed, It SLUBROGATION 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
certiflcate holder In lieu of such andorsement(s)
)iy CONTACT Palos Verdes Ina
PRODUCER ry�T�u"
29U Insurance Services a¢ti. (800) 955 -5578 600)510.5725
L�9+
Af Z_�
Palos Verdes Ins., Agency Inc, MAIL
314 Vista Del Mar, PO Box 636 INS A?nR(§ FOk0LPj _CpuE6tAC .. _ NAICM
Redondo Beach CA 90277 -0636 It y!RFIRA,cL7it fT aourit Insurance Co 24082 ..,
_..... ... ,.._.m, _ . i
INSURED IN5URE9 B_,_,,,,. �..,.- - .,...,,.., ...,.._.,, .... �_._..M..
Allen Pachtman, Robert Reiss, Ivan Reed, David Weiss 114SURERC.:
DBA Westchester Medical Group 1NSURERD±
360 N Sepulveda Blvd Ste 3000 INSURE0E --
El Segundo CA 90245 VN"i RRE2 F i
COVERAGES CERTNICAT'E CdUMEIER:2016 -2017
REVISION NUMBER,
THIS IS "tO C RTNFY THAT THE POLICIES OF INStIRANCE LISTI D BELOW HAVE BEEN ISSUED TO THE fNSVRED NAMED ABOVE FOR "f HE POLICY PERIOD
tlTION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH THIS
IN
CERTNFNCATE htAY BE ISSUED OR IWAY PERTAIN, TTIE IN'SkJftANCE AI EORDEU BY THE POLICIES DESCRIBED
HEREIN IS SUBJECT TO ALL THE TERMS,
REDUCED BY PAID CLAMS.
EX VE BC N
"-..P
O SITe. �. P iLICYEFF PLICM"EXP
LIAIC'S
iI�9R TYPB OF Id1_S.,.U— RANCE. tl Y N. M
21000,000
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE S .,
arrd REIiTEti 500,000
A CLAIMS -MADE OCCUR
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X BX856298065 1/2/2016 1/2/2017
15, 000
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APPLIES PER.
GUN 'L AGGREGATE LIMIT APPLIES PER.
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PRODUCTS- COMPdOPAOO 5�4, 000, 000
—
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OTH'ErCt.
MaVntl -. $ 1, 000, 000
AUTOMOBILE LIABILITY
..t- .,,..,. .m„ ... ....®..... .. "..�...,.»- ._w.........__�_._ —.
• --" - -»
BODILY INJURY (Per person) $ w.......
A , ANY AUTO BA.SS629B065 "' 1/2/2016 1/2/2017
' ALL OMED "'� SCHEDULED
BODILY - v.�.,...._....�
DILY INJURY ('PSrIawd0v1q S
AUTOS ...._....
rLt".�9�Id9sTII_� $
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. HIRED AUTOS AUTOS
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UMBRELLA LIAB OCCUR
EACH OCCURRENCE 1 �..._._...,
6.....�«.W...e-
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AND EMPLOYERS' LIABILITY Y t N
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ANY PROPRfETCir AlIT'ipERfEXECUTIVE NIA '.....
'�9FTICEWMEMBER EXCLUDED?
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EA EN,M1PI I, YE'
(Mandatary In NH)
it as descoba ur&r
q NS I
E,L. DISEASE • . ^
E L, DISEASE . POLCY LIMIT $
DESTtiAM ION F .111'
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, AddI1140sl Remarks Schodult, may Do oMecNod Ir Mors specs Is required)
to liability per form
The Certificate holder is hereby named as additional insured with reapecta
general
#GECG602 (01 /11)
Page 4 of 4 Paragraph B
,am _rn CANCELLATION
City of E1 Segundo, Officials and
Employees
Attn:' Administration Services
350 Main Street
El Segundo, CA 90245 Oer.Ii,a,e Butter /VICKIE
0'1988.2014 ACORD
The ACORD name and logo are registered marks of ACORD
SHOULD NOTICE WILL CANCELLED BEFORE
WILLBEDELWERED
THE IN
ACC'ORDANCK MATH THE POLICY PROVISIONS-
AUTHORIZED REPRESENTATIVE
ACORD 25 (2014101)
INS025 (201401)
CORPORATION, All rights reserved,
F*
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 organize -
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; _ n ..... ..w. .
.. _....., .,_,R
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;
If. Demonstration, installation, servicing or repair operations, except such operations performed
at the vendor's promises 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:
m 2013 Liberty Mutual Insurance
CO 88 62 04 13 Includes copyrighted material of Insurance Services Cfftcs Inc., with Its permission. Page 1 of 1
ACORD CERTIFICATE OF LIABILITY INSURANCE /25/2016
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(I'es) must be andorsed, It 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 a .
PRODUCER Shannon Bailey
Michael Ehrenfeld Company SA (619) 683 -95190 qI: (619)6es -s99a�
2655 Camino Del Rio North I�isl( stiannonbQehrenfeldinsurance.com
#200 INSUREMS) AFFORDING COVERAGE NAIL M
San Diego CA 92108 N� URERA Preftrredlr rs Insurance
INSURED INSURERe;. __.
Westchester Medical Group INSURER C; . _ .........
360 N. Sepulveda Blvd INSURER D c
Suite 3000 INSURF-RE: ,,,_,_�_„_....�........W ..m
El Segundo CA 90245 INSURER F ;
COVERAGES CERTIFICATE NUMSER:16 -17 REVISION NUMBER:
THIS IS TO CERTIFY' THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN WILED 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.
INS!! LION" EFF E LIMITS womni-
L TYPE OF INSURANCE POLICY ME R (MM I
COMMEACIAL GENERAL LIABILITY EACH OCCURRENCE S
CLAIMS -MADE OCCUR --
.� MED EXP Arw ons Parsoaro} S
PERSONAL S ADV INJURY S ..
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AG43REGAIE 1 $
POLICY
PRO- LOC PRODUCTS - OOMPIOP' AGO $
$ _...
OTP(ER,
AUTOMOBILE LIABILITY $
BODILY INJURY (Per person) S
ANY AUTO
- ALL OWNED SCHEDULED
BODILY INJURY (Per acIdan1) S
AUTOS NON -OWNED S
P RT `DAM
r n
HIRED AUTOS AUTOS �, 5
UMBRELLA LIAR OCCUR EACI"J OCCURRENCE S
EXCESS UAB CUVMS -MADE AGGREGATE 5
DE,D RETENTIONS S
WORKER'S COMPENSATION X T" .
AND EMPLOYERS' LIABILITY NIA MDN1410627 8/1/2016 8/1/2017 R, dOISEnASE. - EA, EMPLOYEE _!__1,P09 'OD„,
YIN E L EACH ACCIDENT
ANY PROPRIETCIIIPARTNEfNXXECUTIVE'.
OI"FdCERfME @u48ER EXGLUOED7'
A (Mandatofy In NI1I
It gas,desedbawndpr
D E SCRIPTION OF OPERATIONS oa ID-
E,L. DISEASE . » POLICY LIMIT S 1. DDG fYtl(I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached Ir more space 10 required)
CERTWIC'ATE 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
Cabe Erie /SB
©1988.2014 ACORD CORPORATION, All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
INS025 017114n11
COOPERATIVE OF
AMERICAN PHYSICIANS
CERTIFICATE OF COVERAGE AND CLAIMS HISTORY
Coverage through December 31, 2016
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 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
5906 Internal Medicine September 1, 1990 January 1, 1986
Subspecialty
Sports Medicine, Primary Care
Coverage (Claims made and paid) Current Limits of Llablllty
$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 S30,000 that were made to
patients through MPT's Patient Assistance Services program.
Cooperative of American Physicians, Inc.
January 13, 2016
Alfred DeLeon Date
Vice President, Membership Services
Mutual Protection Trust
�0
...
COOPERATIVE OF
AMERICAN PHYSICIANS
CERTIFICATE OF COVERAGE AND CLAIMS HISTORY
Coverage through December 31, 2016
Member: Allen Pachtman, MD
Address: 360 N. Sepulveda Blvd., #3000
El Segundo, CA 90245
This certificate confirms that, on the dale 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 inlerindemnity
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.
Claim 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.
. w January 13, 2016
Alfred De Leon Date
Vice President, Membership Services
Mutual Protection Trust
COOPERATIVE OF
AMERICAN PHYSICIANS
CERTIFICATE OF COVERAGE AND CLAIMS HISTORY
Coverage through December 31, 2016
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 interindemnily
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.
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 13, 2016
Alfred De Leon Date
Vice President, Membership Services
Mutual Protection Trust