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PROOF OF INSURANCE (2019 - 2020) CLOSED r,, DATE(MM/DDIYYYY) ACOWO CERTIFICATE OF LIABILITY INSURANCE 1%�" 10/28/2019 2/5/2019 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. i IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 .... Lockton Insurance Brokers,LLC NAME. 725 S.Figueroa Street,35th Fl. PHONE FAX g .No,Ext); QNC,Not CA License#OF15767 E-MAIL Los Angeles CA 90017 A,r2QRkS_S (213)689-0065 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Columbia Casualty Company 31127 INSURED Vital Medical Services,LLC INSURER B:State Compensation Ins Fund of California 35076 1407912 550 North Brand Boulevard,Suite 1850 INSURER C Glendale CA 91203 INSURER D INSURER E INSURER F�. COVERAGES VITME01 CERTIFICATE NUMBER: 13864355 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR ,,,,,,„,,,,,,,,,,,,,,,,,,,,,,,,,,,,, INSD WVD POLICY NUMBER (MMIDD/YYYY) _LM IAffiSDPN YYY'd._ _„_,..... A X Y Y HMA 4032281842-3 1/5/2019 1/5/2020 5 50,00,000 COMMERCIAL ( „OAFS:G RL N'1 t,0 ,ucy� $ 20000 MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY s 2,000,000 GEN°L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PFzti”JEC1 7 LOC PRQoucTs-cQMProP AGG $ 4,000,000 (:1T'I.VERd $ AUTOMOBILE LIABILITY NO-1 APPLICABLE. �-...........www. COMBINED MBINE,D�'SINULE LIIPtr"I11 $ XXXXXXX ANY AUTO BODILY INJURY(Per person) S XXXXXXX OWNED SCHEDULED BODILY INJURY $ XXXXXXX(Per accident) $ XXXXXXX AUTOS ONLY AUTOS HIRED NON-OWNED PROPLtd'9S'IDAIAAGE' X -_ AUTOS ONLY AUTOS ONLY (F ar x !dw a s XXXXXXX UMBRELLA LAB OCCUR NOT APPLICABLE EACH OCCURRENCE S XXXXXXX„ l EXCESS LAB CLAIMS-MADE AGGREGATE $ XXXXXXX DED �...........'I RETENTIONS..... $ XXXXXXX PER EMPLOYERS'LIABILITY OP® YPROPRIIETOER EXCLUDED? �-r Y 9116288-2018 10/28/2018 10/28/2019 ER EACH ACCIDENT H WORKERS COMPENSATION JI Y NIA (Mandatory in NH) 5 1,0001010 E L DISEASE-EA EMPLQYEE.$ 1.Ql)���10(I If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S 1,000,000 A Prof.Liab. N N HMA 4032281842-3 1/5/2019 1/5/2020 $2,000,000 Per Cairn Claims Made-Metro Date 54,0()0,000 Aggregate 12/31/2015 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 909,Additional Remarks Schedule,may be attached if more space is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER,APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S)REFERENCED City of Gl 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.Waiver of Subrogation applies per attached endorsement(s)or policy language. CERTIFICATE HOLDER CANCELLATION lee Alttichinenis 13864355 City of El Segundo Police Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Lt.Jeff Le 177ari THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St El Segundo CA 90245 AUTHORIZED REPR ©1 88-201 C D CORPORATION. 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: 1/5/2019 Forms a part of policy no.: HMA 4032281842-3 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 ..F8 .i 4:0,'.'V11"AL February 13th,2018 Lill Sandoval Deputy City Clerk City OF EI Segundo 350 Main Street EI Segundo,California 90245 Dear Lill, I wanted to update our previously approved letterfrom 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: D539987 Certificate ID: 13864355 STATE WAIVER OF.,' SUBROGATION Bl..,ANFET BASIS FUND HOMEOFFICE SAN FRANCISCO EFFECTIVE OCTOBER 28, 2018 AT 12 . 01 A.M. AND EXPIRING OCTOBER 28, 2019 AT 12 . 01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME VITAL MEDICAII.., SERV].(--'E,S, 111.1c 655 N CENTRAL AVE FL 1.7 GLENDALE, CA 91203 WE [[AVE THE RIGHT TO RECOVER. OUR PAYMP.",NTS FROM ANYONE LIABLE FOR AN .1 NJ U R Y COVERED BY THIS POLICY. WE WII..,r.., NOT ENFORCE OUR RIGHT AGAINST I'HE PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. T[i [S AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT R. EOU11(p.].S YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2 .00% OF THE TOTAL POLICY PREMIUM. S CH E D U f..,E PERSON OR ORGAAJOB .... DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER OF SUBROGATION 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 3, 2018 2572 SCIF FORM 10217 IREV 7-2014) OLD DR 217