PROOF OF INSURANCE (2019) CLOSED No:252793875 Return Address
This Certificate is provided to: UCLA Health System
City of EI Segundo 757 Westwood Plaza
350 Main Street Los Angeles, CA 90095
EI Segundo CA 90245
UNIVERSITY OF CALIFORNIA
EVIDENCE OF SELF-INSURANCE
PROFESSIONAL LIABILITY& HOSPITAL LIABILITY
Type of Coverage Self-Insured Limits
I. PROFESSIONAL MEDICAL AND HOSPITAL LIABILITY: 1,000,000 Each Occurrence
3,000,000 Aggregate
II.SPECIAL TERMS&CONDITIONS:
1. This certificate is issued in connection with work performed by:
Greg Carpenter at City of EI Segundo, 350 Main Street, EI Segundo, CA 90245
This certificate is only valid for work performed within the course and scope of his/her employment within:
Center for Prehospital Care at University of California, UCLA Health System
University employees are provided a University funded defense and indemnification for alleged negligence
acts or omissions rising out of the course and scope of the University employment except where they act or
fail to act because of actual fraud, corruption, or actual malice. (California Tort Claims Act. Government
Code Section 810).
2. The self-insurance evidenced herein follows the provisions of the Bylaws and Standing Orders of the
Regents of the University of California and self-insurance programs as administered by the University of
California, Office of the President, Office of Risk Services, which do not permit any assumption of liability
which does not result from and is not caused by the negligent acts or omissions of its officers, agents, or
employees. Any indemnification or hold harmless clause with broader provisions than required under such
Bylaws and Standing Orders shall invalidate this certificate.
3. This certificate is in effect until the expiration date indicated below or termination of applicable contract,
affiliation agreement or termination of University employment,whichever comes first.
Should any of the above described program of self-insurance be materially modified or cancelled before the
expiration date shown below, The Regents of the University of California will give 30 days written notice to the
certificate holder.
Effective Date:07/01/2018 Johanna Klohn
UCLA Health System
757 Westwood Plaza
Los Angeles CA 90095
Expiration Date:07/01/2019 Approval Date:6/15/2018
This Certificate is issued as a matter of information only and confers no rights upon the certificate holder. The Certificate does not
amend, extend or alter the coverage described above. This certificate does not constitute a contract between the holder and the
University of California.
Form:PL Individual 0914