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AGENCY CUSTOMER ID: CONCGRO-01 <br />LOC #: <br />AGENCY <br />The Graham Company <br />POLICY NUMBER <br />CARRIER <br />ADDITIONAL REMARKS <br />ADDITIONAL REMARKS SCHEDULE <br />NAIC CODE <br />NAMED INSURED <br />Occupational Health Centers of California, <br />A Medical Corporation, c/o Select Medical Corporat <br />4716 Old Gettysburg Road <br />Mechanicsburg PA 17055 <br />EFFECTIVE DATE: <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br />Page 1 of 1 <br />KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244600-8; Effective 1/1/2022-1/1/2023 - <br />$500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon <br />LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-8; Effective 1/1/2022-1/1/2023 - <br />$100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon <br />NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-8; Effective 1/1/2022-1/1/2023 - <br />$500,000 Each Medical Incident/$1,000,000 Aggregate Per Insured or Surgeon <br />PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-8; 1/1/2022-1/1/2023 - <br />$500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon <br />WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-8; 1/1/2022-1/1/2023 - <br />$1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon <br />PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions <br />KERS COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Liberty Mutual Insurance Corp. - Policy <br />i-63D-510199-312; Effective: 4/1/2022-4/1/2023 <br />DRKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Insurance Corp. - Policy #WA7-63D-510199-402; Effective: <br />/2022-4/1 /2023 <br />WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Mutual Insurance Corp. - Policy #WC5-631-510199-252 (WI); <br />Effective: 4/1 /2022-4/1 /2023 <br />�] ► IG1 ��ON] :7 :1 � :i.YK�] di I » ► 69G� � [�] ► � li] � [9 I �91 <br />C of Arkansas — Liberty Insurance Corp. - Policy #WC7-631-510199-282; Effective: 4/1/2022-4/1/2023 <br />C of Southwest (AZ/UT) — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-242; Effective: 4/1/2022-4/1/2023 <br />C of Delaware — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-332; Effective: 4/1/2022-4/1/2023 <br />C of Georgia/Hawaii — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-382; Effective: 4/1/2022-4/1/2023 <br />C of Illinois — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-412; Effective: 4/1/2022-4/1 /2023 <br />C of Louisiana — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-292; Effective: 4/1/2022-4/1/2023 <br />C of Michigan — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-272; Effective: 4/1/2022-4/1/2023 <br />C of Nebraska — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-372; Effective: 4/1/2022-4/1/2023 <br />C of New Jersey — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-262; Effective: 4/1/2022-4/1/2023 <br />C of North Carolina — Liberty Insurance Corp. - Policy #WC7-631-510199-342; Effective: 4/1/2022-4/1/2023 <br />C of Southwest (KS) — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-422; Effective: 4/1/2022-4/1/2023 <br />!rapy Centers of Southwest I, PA (OR) - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-392; Effective: 4/1 /2022-4/1 /2023 <br />!rapy Centers of South Carolina, PA - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-302; Effective: 4/1/2022-4/1/2023 <br />C of Minnesota - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-452; Effective: 4/1/2022-4/1/2023 <br />C of Alaska - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-442; Effective: 4/1/2022-4/1/2023 <br />BER LIABILITY - AIG Specialty Insurance Company - Policy #01-613-93-03; Effective: 9/25/2021-9/25/2022 - Limit: $10,000,000 <br />EXCESS CYBER LIABILITY - Endurance American Specialty Insurance Company - Policy #NVX30011525100; Effective: 9/25/2021-9/25/2022 - Limit: <br />$10,000,000 Excess of $10,000,000 <br />CRIME COVERAGE - National Union Fire Insurance Company of Pittsburgh, PA - Policy #02-406-10-33; Effective: 12/31/2021-12/31/2022 - Limit: $10,000,000 <br />Coverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured, but only for professional services <br />performed for or on behalf of the above Named Insured. <br />RE: OHC OF CA/CMC HAS AN AGREEMENT UNDER # A-2019-006 TO PROVIDE MEDICAL SERVICES TO THE EMPLOYEES OF THE NAMED CLIENT. <br />CITY OF SANTA ANA, ITS OFFICERS, AGENTS, VOLUNTEERS AND EMPLOYEES are all included as additional insureds on the above General Liability, <br />Auto Liability and Umbrella Liability Policies and coverage shall apply on a Primary and Non -Contributory basis if required by written contract. <br />Prior to loss, and if required by written contract, Waiver of Subrogation is provided on General Liability, Auto Liability, Umbrella Liability and Workers <br />Compensation Policies for work performed under contract if permissible by state law. <br />ACORD 101 (2008101) © 2008 ACORD <br />The ACORD name and logo are registered marks of ACORD <br />Risk ManaganadDlMsian <br />n49%, REVIEWED &APPROVED BY: <br />z <br />—r- Risk Management Specialist <br />