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<br />O �®
<br />ACC� �V/CERTIFICATE OF LIABILITY INSUMUie b
<br />DATE(AQM/DD/YYYY)
<br />Angpo22
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT ON THE CEr.TI,;CR. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE C ���tt�TL�ICIE,
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT B
<br />r. I
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL IN rU'<ED provi
<br />b d
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may requi,e in endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />The Graham Company
<br />The Graham Building
<br />1 Penn Square West
<br />CONTACT
<br />NAME: Concentra Unit
<br />PHONE FAX
<br />A/C No Ext : 215-567-6300 A/C, No
<br />: 215-405-2694
<br />ADDE-MRESS: Concentra_Unit@grahamco.com
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC#
<br />Philadelphia PA 19102-
<br />INSURERA: Columbia Casualty Company
<br />31127
<br />INSURED CONCGRO-01
<br />Occupational Health Centers of California,
<br />A Medical Corporation, c/o Select Medical Corporat
<br />INSURERB: Liberty Mutual Fire Ins. Co.
<br />23035
<br />INSURERC: Liberty Insurance Corporation
<br />42404
<br />INSURERD: Liberty Mutual Insurance Group
<br />23043
<br />4716 Old Gettysburg Road
<br />Mechanicsburg PA 17055
<br />INSURERE: American Guarantee & Liability Ins. Co.
<br />26247
<br />INSURERF: Allied World Assurance Company, AG
<br />COVERAGES CERTIFICATE NUMBER:224654018 REVISION NUMBER:
<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 />POLICYNUMBER
<br />POLICY EFF
<br />MM/DD
<br />POLICY EXP
<br />MM/DD
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />Y
<br />HAZ4032244581-6
<br />1/1/2022
<br />1/1/2023
<br />EACH OCCURRENCE
<br />$1,000,000
<br />CLAIMS -MADE OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 500,000
<br />X
<br />MED EXP (Any one person)
<br />$
<br />Professional Lia
<br />X
<br />$1M Claim/$3M Ag
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 3,000,000
<br />PRO-
<br />POLICY JECT ❑ LOC
<br />X
<br />PRODUCTS - COMP/OP AGG
<br />$ 3,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />Y
<br />Y
<br />AS2-631-510199-322
<br />4/1/2022
<br />4/1/2023
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$2,000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />A
<br />X
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />Y
<br />Y
<br />HMC4032235752
<br />1/1/2022
<br />1/1/2023
<br />EACH OCCURRENCE
<br />$9,000,000
<br />AGGREGATE
<br />$ 10,000,000
<br />EXCESS LAB
<br />CLAIMS -MADE
<br />DED X RETENTION $
<br />$
<br />G
<br />D
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />Y
<br />WA7-63D-510199-352
<br />WC5-631-510199-362
<br />4/1/2022
<br />4/1/2022
<br />4/1/2023
<br />4/1/2023
<br />PER OTH-
<br />STATUTE ER
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />OFFICER/MEMBER EXCLUDED? ❑
<br />N/A
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />E
<br />Property
<br />ZMDO119116-06
<br />1/1/2022
<br />1/1/2023
<br />SEE BELOW
<br />F
<br />Excess Liability
<br />CO23701-007
<br />1/1/2022
<br />1/1/2023
<br />$10M Each Occurrence
<br />$10M Aggregate
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis.
<br />Both Coverages are excess of a $3,000,000 Self -Insured Retention each Occurrence/Claim subject to a $18,000,000 Aggregate.
<br />PROFESSIONAL LIABILITY COVERAGE includes Case Management Services including the rendering of case management or utilization review performed by
<br />insured for others.
<br />INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-8; Effective 1/1/2022-1/1/2023 -
<br />$500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon
<br />See Attached...
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />CITY OF SANTA ANA ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division
<br />20 CIVIC CENTER PLAZA AUTHORIZED REPRESENTATIVE
<br />SANTA ANA CA 92702
<br />iE
<br />Risk Management DMsian
<br />REVIEWED & APPROVED BY:
<br />@ 1988-2015 ACORD
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD _=_r,__ Risk management Specialist
<br />is
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