CONCENTRA MEDICAL CENTER dba OCCUPATIONAL HEALTH CENTERS OF CALIFORNIA

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AGENCY CUSTOMER ID: CONCGRO-01 LOC #: AGENCY The Graham Company POLICY NUMBER CARRIER ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE NAIC CODE NAMED INSURED Occupational Health Centers of California, A Medical Corporation d/b/a Concentra, Inc. 4714 Gettysburg Rd. Mechanicsburg PA 17055 EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Page 1 of 1 KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244600-8; Effective 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-8; Effective 1/1/2022-1/1/2023 - $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-8; Effective 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,000,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-8; 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-8; 1/1/2022-1/1/2023 - $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions KERS COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Liberty Mutual Insurance Corp. - Policy i-63D-510199-311; Effective: 10/1 /2020-4/1 /2022 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Insurance Corp. - Policy #WA7-63D-510199-401; Effective: 10/1 /2020-4/1 /2022 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Mutual Insurance Corp. - Policy #WC5-631-510199-251 (WI); Effective: 10/1 /2020-4/1 /2022 �] ► IG1 ��ON] :7 :1 � :i.YK�] di I » ► 69G� � [�] ► � li] � [9 I �91 C of Arkansas— Liberty Insurance Corp. - Policy #WC7-631-510199-281; Effective: 10/1/2020-4/1/2022 C of Southwest (AZ/UT) — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-241; Effective: 10/1/2020-4/1/2022 C of Delaware — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-331; Effective: 10/1/2020-4/1/2022 C of Georgia/Hawaii — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-381; Effective: 10/1/2020-4/1/2022 C of Illinois — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-411; Effective: 10/1 /2020-4/1/2022 C of Louisiana — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-291; Effective: 10/1 /2020-4/1 /2022 C of Michigan — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-271; Effective: 10/1/2020-4/1/2022 C of Nebraska — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-371; Effective: 10/1 /2020-4/1/2022 C of New Jersey — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-261; Effective: 10/1/2020-4/1/2022 C of North Carolina — Liberty Insurance Corp. - Policy #WC7-631-510199-341; Effective: 10/1/2020-4/1/2022 C of Southwest (KS) — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-421; Effective: 10/1 /2020-4/1/2022 !rapy Centers of Southwest I, PA (OR) - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-391; Effective: 10/1/2020-4/1/2022 !rapy Centers of South Carolina, PA - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-301; Effective: 10/1/2020-4/1/2022 C of Minnesota - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-451; Effective: 10/1/2020-4/1/2022 C of Alaska - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-441; Effective: 10/1 /2020-4/1/2022 BER LIABILITY - AIG Specialty Insurance Company - Policy #01-613-93-03; Effective: 9/25/2021-9/25/2022 - Limit: $10,000,000 EXCESS CYBER LIABILITY - Endurance American Specialty Insurance Company - Policy #NVX30011525100; Effective: 9/25/2021-9/25/2022 - Limit $10,000,000 Excess of $10,000,000 Coverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured, but only for professional services performed for or on behalf of the above Named Insured. RE: OHC OF CA/CMC HAS AN AGREEMENT UNDER # A-2019-006 TO PROVIDE MEDICAL SERVICES TO THE EMPLOYEES OF THE NAMED CLIENT. CITY OF SANTA ANA, ITS OFFICERS, AGENTS, VOLUNTEERS AND EMPLOYEES are all included as additional insureds on the above General Liability, Auto Liability and Umbrella Liability Policies and coverage shall apply on a Primary and Non -Contributory basis if required by written contract. Prior to loss, and if required by written contract, Waiver of Subrogation is provided on General Liability, Auto Liability, Umbrella Liability and Workers Compensation Policies for work performed under contract if permissible by state law. ACORD 101 (2008101) © 2008 ACORD The ACORD name and logo are registered marks of ACORD cF Risk Management Division REVIEWED & APPROVED BY: v --� RFsk janagement Analyst