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PROOF OF INSURANCE (2018) CLOSED DATE(MM/DD/YYYY) AC"RO CERTIFICATE OF LIABILITY INSURANCE 8/31/2017 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 riqhts to the certificate holder in lieu of such endorsement(s). PRODUCER NAME CT Michelle Goodwin, CIC, CISR, CPSR i InterWest Insurance Services PHONE 831-635-2247 FAX831-638-6801 Y License#OB01094 (AIC,No,Ext): . (AIC.N,II E'IMAIL 222 Court Streetm oodwi wins.com CI Woodland CA 95695 INSU,RE,,�yRS),AFFORDINGY,COVERAGE I, NAIC# ADOCSS, INSURER A: .., I Liberty Mutual Fire Ins Co. 123035 INSURED USHEA-1 INSURER B.Liberty Insurance Corporation 142404 U.S. Ste 200 INSURER D! National Casualty Corp 15105 2524 Springfield Ct., Valencia CA 91355 INSURER E INSURER F: COVERAGE'S CERTIFICATE NUMBER'. 1461625855 '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 URRPOLICY EFF BY PAID CLAIMS I1N.TR.... IINSD SWVD POLICY NUMBER (MW'DDIIYYV'Y1 POLICY EXP,,, TYPE OF INSURANCE IMOLICY YYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y TB2691450294037 9/1/2017 9/1/2018 EACH OCCURRENCE $1,000,000 .,J PREM,S„E 1„O a„ ,CLAIMS-MADE IX I OCCUR EMESfE occurrence) $1.000.000 MEDE�XP(Any one person) $10,000 „ ��, PERSONAL&ADV INJURY $1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $2,000,000 ®OH . POLICY ( PRO- X I LOC PRODUCTS $2.000,000 JECT A AUTOMOBILE LIABILITY AS2691450294047 9/1/2017 9/1/2018COMBINED;,I • LI MI $1,000,000 X I ANY AUTO BODILY INJURY(Per person) $ OWNEDSCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PkOf�yrRTY DAMAGE'! AUTOS ONLY AUTOS ONLY (Por�aix,Pdo,M) $ B X UMBRELLA LIAB X OCCUR TH7691450294057 9/1/2017 9/1/2018 EACH OCCURRENCE $25,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $25,000,000 DED IX I RETENTION$10„000 $ C WORKERS COMPENSATION LDC4042721 9/1/2017 9/1/2018 X PER I I ERH _ AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE F NIA EL EACH ACCIDENT $2,000,000 OFFICER/MEMBER EXCLUDED? ° (Mandatory in NH) E L DISEASE-EA EMPLOYEE $2,000,000 If yes,de5or+lye under DESCRWPPrION 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) Re: 390 North Sepulveda Blvd, EI 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 payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo,its officials,employees THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street,Room 5 ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo CA 90245-3813 AUTHO�RgIpZED®®gR��EPRESENTATIVE I w"tltl ©1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 Policy Number: TB2691450294037 Effective Date: 09/01/17 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O CONTRACTORS SCHEDULED PERSON O ORGANIZATION" This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location(s)Of Covered Operations Or Organization(s): ANY ENTITY FOR WHOM YOU ARE PERFORMING ALL COVERED PROJECTS ONGOING OPERATIONS, BUT ONLY IF REQUIRED BY WRITTEN CONTRACT PRIOR TO AN "OCCURRENCE"OR LOSS Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who is An Insured is does not apply to "bodily injury" or"property amended to include as an additional insured damage" occurring after the person(s) or organizations(s) shown in the Schedule, but only with respect to 1.AII work, including materials, parts or liability for"bodily injury", "property damage" equipment furnished in connection with or "personal and advertising injury" caused, such work, on the project (other than in whole or in part, by: service, maintenance or repairs) to be performed by or on behalf of the additional 1. Your acts or omissions; or insured(s) at the location of the covered 2. The acts or omissions of those operations has been completed; or acting on your behalf; 2.That portion of"your work" out of which In the performance of your ongoing the injury or damage arises has been put operations for the additional insured(s) at to its intended use by any person or the locations(s) designated above. organization other than another contractor or subcontractor engaged in performing B. With respect to the insurance afforded operations for a principal as a part of the to these additional insureds, the following same project. additional exclusions apply: This insurance CG 2010 07 04 0 ISO Properties, Inc.,2004 Page 1 of 1 a DATE MID AC"R" CERTIFICATE OF LIABILITY INSURANCE 4i2si2o17 DIYYYY) 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 rights to the certificate holder in lieu of such endorsement(s). NOME: ClnterWest Insurance Services PHONE Michelle Goodwin, CIC, CISR,CP FAX License#OB01094 AIC.No,Ext).831-635-2247 FAX No);6831-638-6801 222 Court Street AE'MAIL mgooclWln r�iwlnom s.c c Woodland CA 95695 INSURER(S)AFFORDING COVERAGE NAIC# wsURERA:NORCAL Mutual Ins Company 33200 INSURED USHEA-1 INSURER B: U.S. Healthworks, Inc. INSURERC: 25124 Springfield Ct., Ste 200 Valencia CA 91355 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:599637376 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 NSR TYPE OF INSURANCE IINSO SUER WVD POLICY NUMBER IMMPDDIYYYYI IMMW0tYYY POLICY'EFF POLICY EXP Yp LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ .,,., CLAIMS-MADE OCCUR bAMAGIE 70 TO PREMISE`,'EI�rgh�csIaNppe) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY LOC PRODUCTS C S-COMP/OP AGG $ OTHER. $ �r T ,AUTOMOBILE LIABILITY ( C deU SIl�l-' b l,IMIr $ E P P. ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Peraccidenl) $ HIRED NON-OWNED 'P'AOPbV,-',R1YDMA AGL $ AUTOS ONLY AUTOS ONLY I.Por rdrrfen9y $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS S LIAB CLAIMS-MADE AGGREGATE $ DED V l RETENTION 3 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN p STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ A Medical Malpractice 721820E 5/1/2017 5/1/2018 Aggregate $3,000,000 A Professional Liability 721823N 5/1/2017 5/1/2018 Limit $1,000,000 $150,000 Ded IL/CAlTX/FL/WA Ded-All Other States $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more 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.Health Works,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 390 N.Sepulveda,Suite 1000 ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo CA 90245 AUTHORIZED REPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD