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PROOF OF INSURANCE (2018 - 2019) CLOSED or IDENCE W N�11101, m W, Health & Services CERTIFICATE OF INSURANCE Providence Health&Services Providence Medical Institute 1801 Lind Avenue SW#9016 5315 Torrance Blvd.,Suite A Renton,WA 98057-9016 Torrance,CA 90503 Effective 6/1/03 Providence Health&Services Self-funded Professional and General Liability Program covers the employees of Providence I-teelth&Services(P,H&S)while,acting within the scope and during the Course Of their employment with Providence Health&Services,for all!acts that are normally covered by customary professional liability insurance policies, This program is continuous and does not expire;however,termination of employment, terminates coverage for future acts. General Aggregate $ 4,000,000 Professional and General Liability. Products-Comp/Op Agg $ Included Professional and General Liability,Errors and Personal&Adv Injury $ Included Omissions(malpractice) Each Occurrence $ 2,000,000 Contractual Liability,Managed Care, Fire Damage(Any one fire) $ Included Includes Fire Damage,Legal. Because this Is funded through a PHS trust Medical Expense(Any one there is no"policy number' person) $ Included Policy FIfective Dales� Coverage provided by Providence Health&Services Self-Insured Professional and General Liability Program Is continuous and applicable to all professional liability claims occurring while the Providence Health&Services employs the provider Irrespective of when a claim Is made. Location: 360 N Sepulveda Blvd.,Suite 3000,Ell Segundo,CA 90245 Additional Insured as respects to general liability: The City of El Segundo,Officials and Employees Certificate issued with express authorization of Providence Health & Services, Martha Raymond, Vice President, Risk, Claims and Insurance. This document is conferred as information only,does not after coverage afforded by the Self-insurance Certificate Lwued TO: Plan In any way,and guarantees the holder no rights beyond those extended in the policy. The City of El Segundo,Officials and Employees Attn:Administration Services 350 Main Street 77'1�,��,IDENCE El Segundo,CA 60245 Health&Services Date issued: January 5,2017 1801 Lind Avenue SW#9016 Tel 425-525-3395 Renton,WA 98057-9016 Fax 425-525-3589 Email: C,,\Users\cwelfrnon\AppData\tocal\Temp\Templ_FIV_Westchester_GelleraLi;abiiigy_coverago-for-contract_&Mfistions 2017.zfp\The C11yotV Segundo,doc Copies of this cerlifteate should be considered OQUOY valid to the 011911104 CERTIFICATE OF LIABILITY INSURANCE I D0611%0ill 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), PRODUCER CONTACT r Marsh USA,Inc. 'PHONE _ _... X _.-..-... 130151h Avenue Slue 1900 Seattle,WA'98161 AMML ..,... . . __ _, INSURER( AFFgfRDINqCOVERAGE — 230­11135 At'CP CN 8985706.•Aulo4849 INSURER A!Ul:�'cty Mutuat Fite Irlsuraance Cone �,w„ ........ . INSURED ProVid oe SL Joseph Health INSURER e; 1801 Und Avenue SW,(19016 INSURER C Renton,WA 98057-9016 INSURER O INSURER F COVERAGES C'ERTIF'ICATE NUMSE'R; SEA43536982-04 REVISION NUMBER. 5 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LUSTED 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 CONDITIONS OF POLICIES.LIMITS SHOWN N MAY HAVE BEEN REDUCED BY PAID CLAIMS, M r YEs POLICY ExPNR" faRAcEPOLICY NUMBER IARLlarS ATaTIrC COMMERCIAL GENERAL LIABILITY E'ACHOCCURRE'NCE S DCLAIMS-MADE OCCUR E_"Fs lea otoartq p $ MED EXP(Any one vanm) S m m PERSONAL a ADV INJURY S EN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE s POLVCY'0I J C FILOC PRODUCTS-COMPIOP AGO S COMe1N D OTHER A AUTOMOBILELIA9IUTY AS26610$66U601$ O6l01C2016 06!0112019 )rNGLE 19NflT S 52,000,000 X ANY AUTO BODILY INJURY(Per Psraon) i OWNEDSCHEDULED I BODILY INJURY(Per acddent) S AUTOS ONLY AUTOSrear C A $ f--�--- e AUTOS ONLY AUTOS ONLY cklatll HIRED NON-OWNED (par T„ UMBREL S p CCCUR EACH OCCURRENCE—— s EXCESS HCLAIMS-MADEEXCEa8LIAeAGGREGATE S Deo r RETENT'I'ON$ � S WORKER$COMPENiAT16N I„& ATtJTE.,., RH AND EMPLOYERS LIABILITY Y I N ANYPROPMETORIPARTNEWEXECUTIVE ❑ NIA I (E.L.EACH ACCIDENT $ C P'P IC E RIM E M SE R E XC'LUO10 (Mandatory In NH) ESL,DISEASE•EA EMPLOYEE,S Mescrbe under IPTION OF OPERATIONS below El,DISEASE-POLICY LIMIT $ DEa:RI'PTION OF OPERATION$I LOCAT'ION'S I VEHICLES(ACORO Let,Addhiotval Remarks Schedule,may t a attached K mon apace Is required) PmWera Me cal Institute„360 N SepuWoa 6tvd Ste 3000,Et$99undo,CA 90245 CERTIFICATE HOLDER CANCELLATION CMy of EI Segundo,OMdak and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Erllploym THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN,Adininist Sef*u ACCORDANCE"TH THE POLICY PROVISIONS. 350 Main Slroet Ei Segundo,CA 90245 AUTHORIZED REPRESENTATIVE .E NTATIVi of Marsh USA Inc, Hekln A.Vrobei wit 1968.2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and(opo ant registered marks of ACORD AC o DATE(MMIDD►yrw) �. CERTIFICATE OF LIABILITY INSURANCE 12/1412017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER{S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT, If the certificate holder Is an ADDITIONAL INSURED,the pollcy(Ias)must have ADDI'T'IONAL.INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A Statement on this certificate does not confer rights to the certificate holder In IWu of suchh endorsement($), Marsh seanM�I ed01 �"1T _...._ _• _ PRODUCER M eatiltI,Av 981 Sone 1900 AO I)._ .. . ._•. _. l.I.,. .W........ ....... . Ann:Jenrifer Caudebec•206.214.3156 --.•- -.....- 14910 •922,16.19 .. INSURER A:Safely NaWI*Cosvelty Oyo, •.,15105 ....._w....... NSURED INSURER B Providence Heenh 8 Services ._............ .ww 1601 Lind Avenue SW 0016R k., Renton,WA 96057.9016 WSJ.0 D .. ._.... INSURER r COVERAGES CERTIFICATE NUMBER,: SEkl)03497940-03 REVISION NUMBER: 1 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. INSR -„ b' R �.._...•...”--r ''"EFS'.».. A'IStG ""i . ..._. _....._ I.TR YYPE DP INSURANCE InJ I POLICY NUMBER aMlaroDrY'wYvw MMIDO(Y YYI LIMITS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE s M.. CLAIMS-MADE OCCUR H6fdJ,6 .•t �r eI s. rED EXP(PAY Orad paraan) s PERSONAL&AovINJURY w_Vim....,�W _ _..�....•.. 0_EN'L AGGREGATE LIMIT APPLIES PER: GENERAL AWRtGATE S POLI'C'Y I JECT LOC PRODUCTS.COMPIOP AGO OTHER: _ s '.. AUTOMOEILE LIAEILITY .. _W11e1P'g1S'IWLC LIMIT a INi�nl9 mm.. ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED DILYIINJURY(Per oxd®nr)I AUTOS ONLYAUTOS HIRED NON-0WNED P ?PERTYC'?AMAO ' AUTOS ONLY AUTOS ONLY (._4 y�011I� S UMBRELLALIAB 1_1OCCUR .. EACHOCCU.RRENCE EXCESS LIAO CLAIMS-MADEJ [AGGREGATE ..n._.....� s Eli 1 �AgTgNT'ION$ p s A WORKERS COMPENSATION sP401912 IONF O PLOYS S'UAI LIT EXCLUDE1XECLncVE' YIN SIR:$2,000,000., U�It1T1 a1a1 0111x1019 a�C ACCi17ENTG EICH M ImS.._ ,000 ,000 t _. rl)ESC IP YOe on aOPERA7VONS Oa4n NIA EµL,DISEASE•POLICY LIMIT ffiµu $..000.000 I I 1 , DESCRIPTION OF OPERATn5N8I LOCATIONS I VEHICLES(ACORD 101,Addalorlal Remarks Schedule,may N akaehad K mon space Is required) PRINlem Medical luft^Internal ne El Segundo,360 N.Sepulveda,EI Segundo,CA 90245,Formerly Weskhea(er Medica)Group Center for Heart and Health. Is' CERTIFICATE HOLDER CANCELLATION The Cny of 8 Segundo,Officials and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Empioyeee THE EXPIRATION DATE THEREOF, NOTICE MILL BE DEUVERED IN ATTN:AdmhisblMlon Services ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI*uW CA 80245 AUTHORIZED REPRESENTATIVE of Marsh USA Ino. I Helen A,Vrebel 144A.4 0190I1'-2016 ACORD CORPORATION, All rights reserved. ACORD 25(2016f03) The ACORD name and logo are registered marks of ACORD COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY NCoverage through December 31,2018 uamomu uu umuouuuouuwru uumomuouu1JIumii i , I 11�1 Member: Robert A.Reiss,MD Address: 360 N Sepulveda Blvd Ste 3000 EI Segundo,CA 90245 This certificate confirms that, effective on the coverage 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 "f 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. 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. December 22,2017 Alfred De Loon Date Vice President,Membership Services Mutual Protection Trust COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Co%"crsgt through December 31,2018 111111111IN11111KII �d;u'!uJjjjjjjjjujjj 111411 Member: Allen Pachtman,MD Address: 360 N.Sepulveda Blvd,,#3000 El Segundo,CA 90245 This w0ficatt crinfinm throat, effective on: the covcrngc datc Wow, the above,-starred' physician is a nioniber or tile Cooperaiivv of American Physicians, lite, (CAP) and a pastiuipaill in the multial Notcclioo Trim (Milli'). WIT is ill% unincorpmaied intefindcminty Organized under California Insurince Codc section 1280,7, This ccriificalc confers no rights upon the nicillber trend does not limend, extend or alter the covc"ligi: arfordcd under the terms, conditions and exclusions of ilio MIYI' Agrcinocni, Membership Number Medical Specialty I Coverage Data Retroactive Coverage Data 5908 Internal Medicine September 1, 1990 January 1, 1986 Subspecialty 'A 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 pony, 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 lost 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. December 22,2017 Alfred Dc Leon Date Vice President,Membership Services Mutual Protection Trust COOPERATIVE...._...,�....... .. OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coverage through December 31,2018 Member: David M.Weiss,MD Address: 360 N Sepulveda Blvd Ste 3000 EI Segundo,CA 90245 This certificate confirms that, effective on the coverage 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 atter 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 t 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. December 22,2017 Alfred De Leon Date Via President,Membership Services Mutual Protection Trust