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PROOF OF INSURANCE (2018 - 2019) CLOSED ACC>R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1. 10/28/20181 12/19/2017 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(les)must have ADDITIONAL INSURED provisions or 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 right's to the certificate holder in lieu of such endors011tent(s). PRODUCER Lockton Insurance Brokers,LLC NAME:CT - NAME; 725 S.Figueroa Street,35th Fl. PHONE FAX CA License#OF15767 E-MAILa'.s x* h/p'"" I' Los Angeles CA 90017 APDR9kS;- (213)689-0065 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Columbia Casualty Company 31127 INSURED Vital Medical Services,LLC INSURER B:State Compensation Iris Fund of California 35076 1407912 655 North Central Ave, 17th Floor INSURER C Glendale CA 91203 INSURER D: INSURER E: INSURER F: COVERAGES VITME01 CERTIFICATE NUMBER: 131164355 REVISION NUMBER; XXXXXXX 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 DOLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR TYPE OF INSURANCE ADDL SUB,. POLICY EFF POLICY EXP LIMITS LTR IN„SD 4WD POLICY NUMBER (MMIDDIYYYY) ,IMMIDDNYYYI A N COMMERCIAL GENERAL LIABILITY Y N HMA 4032281842-2 1/5/2018 1/5/2019 EACH OCCURRENCE s 2,000,000 GAMAGE'YO REN'T'ED CLAIMS-MADE FxI OCCUR PREMISES(Fa occurrence) $ 50,000 X $2,500 Ded MED EXP(Any one person) $ 5,000 BI/PD Comb/Per Occ PERSONAL&ADV INJURY $ 1,000,000 A E LIMIT APPLIES PER GENERAL AGGREGATE $ 4,000,000 X POLICY N'L AGGREGATEI PRO- JECT ( LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBI'NE.D RIN4,LL L,IMII (Ea,svo4ent) $ XXXXXXX ANY AUTO BODILY INJURY(Per person) $ XXXXXXX OOUTOS ONLY AUTWNED OSULED BODILY INJURY(Per accident) $ XXXXXXX HIRED NON-OWNED PROPE°R'IY DAMAd„;E AUTOS ONLY AUTOS ONLY (Per ar,c,ldont) $ XXXXXXX $ XXXXXXX . ... UMBRELLA AB OCw CCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAB CLAIMS-MADE AGGREGATE $ XXXXXXX ... DED RETENTION$ $ XXXXXXX WORKERS COMPENSATION PER OTH- ERAND EMPLOYERS'LIABILITY YIN N 9116288-2017 10/28/2017 10/28/2018 X STATUTE B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E L EACH ACCIDENT $ 1,000,,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1.000.000 A Professional Liab N N HMA 4032281842-2 1/5/2018 1/5/2019 $1M Per Claim Claims Made-Retro Date $3M Agg 1/5/16 $2,500 Ded DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (.CORD 101,Additional Remarks Schedule,may be attached if more space is required) City of EI Segundo Police Department is an additional insured to the extent provided by policy language and/or endorsement(s)issued or approved by the insurance carrier CERTIFICATE HOLDER CANCELLATION See Attachnients 13864355 City of El Segundo Police Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:Lt.Jeff Le man THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Leyman WITH THE POLICY PROVISIONS. 350 Main St El Segundo CA 90245 AUTHORIZED REPR I ©1 $ 2201 fCfOORPORATION. All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT NO. L01 This endorsement, effective 12:01 AM: 1/5/2018 Forms a part of policy no.: HMA 4032281842-2 Issued to: Vital Medical Services, LLC By: Columbia Casualty Company ADDITIONAL INSUREDS ENDORSEMENT The Policy is amended as follows: Section II. WHO IS AN INSURED 01 the HEALTHCARE PROFESSIONAL LIABILITY COVERAGE PART is amended by adding the following: but only as respects liability arising out of the conduct of your business. Section II. WHO IS AN INSURED 01 the HEALTHCARE GENERAL LIABILITY COVERAGE PART is amended by adding the following: but only as respects liability arising out of the conduct of your business. All other terms, conditions and exclusions of the policy remain unchanged. 79523( 5/02) HC0310 Attachment Code:D517303 Certificate ID: 13864355 V'] �w �..�Ww... -w�atrd+::x,a aam,uaa°ca February 13th, 2018 Lill Sandoval Deputy City Clerk City OF EI Segundo 350 Main Street EI Segundo, California 90245 Dear Lili, I wanted to update our previously approved letter from April 16th, 2015 and to advise you that none of the initial conditions have changed. All our staff currently operate their own vehicles and carry their own vehicle insurance. When responses are required by our staff,they will not violate local, state and ore federal laws pertaining to their response.They will continue to abide by all traffic rules and regulations. Please let me know if you need any additional documentation. Respectfully, Alex G. Ghazalpour Chief Operating Officer Vital Medical Services Attachment Code:D544648 Master ID: 1407912,Certificate ID: 13864355 State Compensation Insurance Fund ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS 9116288-2017 RENEWAL SC EFFECTIVE 10/28/2017 AT 12:01 A.M. AND EXPIRING 10/28/2018 AT 12:01 A.M. Vital Medical Services, LLC 655 North Central Ave, 17th Floor Glendale , CA 91203 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. 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 11.2016 SCIF FORM 10217(REV.7-2014)