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CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 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 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 Don Gath Insurance Agency 2199 Temple Ave Signal Hill, CA 90755 License #: 0447779 INSURED / INSUR Cheshire Medical Corp VY/ DBA Procare Work Injury Center INSUR 17232 Redhill Ave INSUR Irvine, CA 92614-5628 INSUR INSUR COVERAGES CERTIFICATE NUMBER. nnnnonnn-19RA41 LECTIT1 unAaCCo. 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. ILTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MIDDIYYYY POLICY E%P M OD LIMITS A rCOMMERCIAL GENERAL LIABILITY / CLAIMS -MADE �OCCU Y Y ACPBP07841060710 03/18@020 / 03/18I2021 � EACH OCCURRENCE $ 1,000,000, DAMAGETORENTED PREMISES Ea oavrtenrx $ 300OOO MED EXP (Any one person) $ 1,000 ✓/ PERSONAL &ADV INJURY S 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY ❑ jEOT LOC GENERAL AGGREGATE S 2000000 GEN'L X PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: B AUTOMOBILE LIABILITY Y Y ACPBP07841050710 03/18/2020 03/1812021 COMBINED SINGLE LIMIT $ 1000000 BODILY INJURY (Perperson) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per amidenp $ X HIRED, X NOFOSWNEO PROPERTY DAMAGE Para dent S 5 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMSMADE AGGREGATE $ DEC I RETENTIONS $ WORKERS COMPENSATION ANDEMPLOVERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED? ❑ NIA PER OTH- GTATUTE I I ER EL EACH ACCIDENT $ E.1- DISEASE - EA EMPLOYEE 3 (Mandatory in NH) If You describe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OFOPERATIONS I LOCATIONS IVEHICLES (ACORD ID1, Additional Remarks Schedule, maybe attached If more space is required) Classification: Medical Clinics City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured on this policy pursuant to written contract, agreement, or memorandum of understanding per PBO448. Such insurance as is afforded by this policy shall be primary, and any insurance carried by City shall be excess and noncontributory per PB0497. Certificate of Insurance shall provide thirty (30) day prior written notice of cancellation per PB2297. By Risk MANAGEMENT Di IISION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Risk Management Division AP 9 2020 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1988, M-28 Santa Ana, CA 92701 ZEO REPRESENTATIVE ANGIE ACEVEdO GMG 198#k014 ACORn CORPORATION All rinNee .o..r 4 ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Printed by GMG on March 24, 2020 at 03:18PM