CONCENTRA MEDICAL CENTER dba OCCUPATIONAL HEALTH CENTERS OF CALIFORNIA

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Dig{affy signed ba ' e Francine R. R. Villareal Vi I IA real Date: 2022.01.0516.32.27 ACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/°D/YYYY) 12/30/2021 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(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 The Graham Company The Graham Building 1 Penn Square West CONTACT NAME: Concentra Unit PHONE FAX A/C No Ext : 215-567-6300 A/C, No : 215-405-2694 ADDE-MRESS: Concentra_Unit@grahamco.com INSURER(S) AFFORDING COVERAGE NAIC# Philadelphia PA 19102- INSURERA: Columbia Casualty Company 31127 INSURED CONCGRO-01 Occupational Health Centers of California, A Medical Corporation d/b/a Concentra, Inc. INSURERB: Liberty Mutual Fire Ins. Co. 23035 INSURERC: Liberty Insurance Corporation 42404 INSURERD: Liberty Mutual Insurance Group 23043 4714 Gettysburg Rd. Mechanicsburg PA 17055 INSURERE: American Guarantee & Liability Ins. Co. 26247 INSURERF: Allied World Assurance Company, AG COVERAGES CERTIFICATE NUMBER: 147834281 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICYNUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y HAZ4032244581-6 1/1/2022 1/1/2023 EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 X MED EXP (Any one person) $ Professional Lia X $1M Claim/$3M Ag PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRO- POLICY JECT ❑ LOC X PRODUCTS - COMP/OP AGG $ 3,000,000 $ OTHER: B AUTOMOBILE LIABILITY Y Y AS2-631-510199-321 10/1/2021 4/1/2022 COMBINED SINGLE LIMIT Ea accident $2,000,000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY A X UMBRELLALIAB X OCCUR Y Y HMC4032235752 1/1/2022 1/1/2023 EACH OCCURRENCE $9,000,000 AGGREGATE $ 10,000,000 EXCESS LAB CLAIMS -MADE DED X RETENTION $ $ G D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N Y WA7-63D-510199-351 WC5-631-510199-361 10/1/2021 10/1/2021 4/1/2022 4/1/2022 PER OTH- STATUTE1 ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 E Property ZMDO119116-06 1/1/2022 1/1/2023 SEE BELOW F Excess Liability CO23701-007 1/1/2022 1/1/2023 $10M Each Occurrence $10M Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis. Both Coverages are excess of a $3,000,000 Self -Insured Retention each Occurrence/Claim subject to a $18,000,000 Aggregate. PROFESSIONAL LIABILITY COVERAGE includes Case Management Services including the rendering of case management or utilization review performed by insured for others. INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-8; Effective 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SANTA ANA ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Division 20 CIVIC CENTER PLAZA AUTHORIZED REPRESENTATIVE SANTA ANA CA 92702 IZAManagzmentDMsian REVIEWED & APPROVED BY.- @ 1988-2015 ACORD C, ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD _ _— task Mran gement Analyst