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Digitally signed
<br />Ac"Mor CERTIFICATE OF LIABILA W E DATE (MMIDDIYYYY)
<br />�.,.,,� /l4 3 n 11Q2022
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS WRIGHTS UPON TF c -FxRTIFICATE H LDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGF AF,Qex*tQPOLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A ZITRACT BETWEEN THE ' UING Ii:`zURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy es) A DI D provisions c: be en orsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may rer,uire an en(yeP q,,:4tten�tt7►
<br />�J 7.lJo.`} �J lJ
<br />D
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).CONTACT
<br />PRODUCER Lockton Companies
<br />_
<br />NAME,
<br />PHONE FAX
<br />A/C No):
<br />8110 E Union Avenue
<br />Suite 100
<br />Denver CO 80237
<br />E-MAIL
<br />ADDRESS:
<br />(303) 414-6000
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Arch Specialty Insurance Company
<br />21199
<br />INSURED WellDyneRX, LLC
<br />1477414 500 Eagles Landing Drive
<br />INSURER B : Zurich American Insurance Company
<br />16535
<br />INSURER C : ACE American Insurance Company
<br />22667
<br />INSURER D : Berkley Insurance Company
<br />32603
<br />Lakeland, FL 33810
<br />INSURER E :
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 14516082 REVISION NUMBER: XXXxxS x
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DD/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />N
<br />N
<br />FLP006017705
<br />2/16/2022
<br />2/16/2023
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE 1XI OCCUR
<br />DAMAGE T
<br />PREM SESOEa occurrDence
<br />$ 100,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 3,000,000
<br />POLICY n PRO -
<br />POLICY F-1 LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 3,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />N
<br />N
<br />FLP006017705
<br />2/16/2022
<br />2/16/2023
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$ XXX)CS XX
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLYNAUTOS
<br />BODILY INJURY (Per accident)
<br />$ XXX�CSCSCS�
<br />Xr
<br />PROPERTY DAMAGE
<br />Per accident
<br />$XXXXXXX
<br />HIRED NON -OWNED
<br />AUTOS ONLYAUTOS ONLY
<br />$ XXXyCS xx
<br />A
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />N
<br />N
<br />FLP006017705
<br />2/16/2022
<br />2/16/2023
<br />EACH OCCURRENCE
<br />$ 10,000,000
<br />A
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />Prof. Liab. RetroDate: 2/16/20
<br />X
<br />AGGREGATE
<br />$ 10,000,000
<br />DED RETENTION $
<br />$ XXXXX�
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />N / A
<br />N
<br />WC014390905
<br />2/16/2022
<br />2/16/2023
<br />EROTH-
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />A
<br />Pharmacy Prof. Liab.
<br />N
<br />2/16/2022
<br />2/16/2023
<br />$1M/$3M Retro Date: 2/16/2020
<br />C
<br />PBM E&O Liab.
<br />=FLPOR046017705
<br />2508130002
<br />2/16/2022
<br />2/16/2023
<br />Limit: $3M/Ret $250K
<br />D
<br />Crime
<br />500242325
<br />2/16/2022
<br />2/16/2023
<br />Limit: $2M per Occ.
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />Per Agreement Master Agreement A-2007-278 and current agreement A-20180-131-01 with the City of Santa Ana, Proof of Worlcers' Compensation Coverage.
<br />14516082
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza
<br />Santa Ana CA 92701
<br />ACORD 25 (2016103)
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE,—
<br />Risk M8118gement DMskrn
<br />+� �m REVIEWED & APPROVED BY:
<br />@ 1 s88-2o ACo
<br />The ACORD name and logo are registered marks of ACORD
<br />r Risk Management Specialist
<br />off
<br />IN
<br />
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