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Francine R. Digitally slg"etl by rra"°"` <br />P, Vllli,eal <br />Villareal mIe2...el os Ucti? 1 <br />ACORO® CERTIFICATE OF LIABILITY INSURANCE <br />DATE/2 <br />12/30/30/202021 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an 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 />Philadelphia PA 19102- <br />CONTACT <br />NAME Concentra unit <br />PHONE FAX <br />215-567-6300 c Nq:215-405-2694 <br />Ei )A Ess: Concentra Unit@grahamco.com <br />INSURERS AFFORDING COVERAGE <br />NAICIt <br />INSURER A: Columbia Casualty Company <br />31127 <br />INSURED CONCGRO-01 <br />Occupational Health Centers of California, <br />A Medical Corporation d/b/a Concentra, Inc. <br />INSURER e: LibertyMutual Fire Ins. Co. <br />23035 <br />INSURER C: LibertyInsurance Corporation <br />42404 <br />INSURERD: Liberty Mutual Insurance Group <br />23043 <br />4714 Gettysburg Rd. <br />Mechanicsburg PA 17055 <br />INSURER E: American Guarantee & Liability Ins. Co. <br />26247 <br />INSURER F: Allied World Assurance Com any, AG <br />COVERAGES CERTIFICATE NUMBER: 147834281 REVISION NUMRER- <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 />ILTR <br />TYPE OF INSURANCE <br />ADDLSUBR <br />POLICY NUMBER <br />POLICYEFF <br />MM/DDIYYYY) <br />POLICYEXP <br />IMWDDIYYYYl <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE [XI OCCUR <br />Y <br />Y <br />HAZ 4032244581-6 <br />1/1/2022 <br />1/1/2023 <br />EACH OCCURRENCE <br />$1,000,000 <br />D MAGE TO RENTED <br />nce PREMISES Eaomurre <br />$500,000 <br />X <br />MED EXP (Any an. person) <br />$ <br />Profession.] LIa <br />$1MCla rn/$3MAg <br />PERSONAL& ADV INJURY <br />$1,000,000 <br />X <br />AGGREGATE LIMIT APPLIES PER: <br />POLICY ❑ JECTPRO- ❑ LOC <br />GENERALAGGREGATE <br />$3.000,000 <br />GEN'L <br />X <br />PRODUCTS - COMPIOPAGG <br />$3,000,000 <br />$ <br />OTHER: <br />B <br />AUTOMOBILE <br />LIABILITY <br />Y <br />Y <br />AS2-631-510199-321 <br />10/1/2021 <br />411/2022 <br />COMBINED SINGLE LIMIT <br />Ea accident <br />$2.000,000 <br />ANY AUTO <br />BODILY INJURY (Per person) <br />$ <br />1X <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY (Per accident ) <br />$ <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />PROPERTY UAMAGE <br />Per aaitlent <br />$ <br />A <br />X <br />UMBRELLA LIAB <br />X <br />OCCUR <br />Y <br />Y <br />HMC 4032235752 <br />1/1/2022 <br />1/1/2023 <br />EACH OCCURRENCE <br />$9,000,000 <br />AGGREGATE <br />S10,000.000 <br />EXCESS LIAB <br />CLAIMS -MADE <br />DED I X I RETENTION$ <br />$ <br />C <br />D <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />Y <br />WA7-63D-510199-351 <br />WC5-631-510199-361 <br />10/l/2021 <br />10/1/2021 <br />4/1/2022 <br />4/1/2022 <br />PER ERH <br />E.L. EACH ACCIDENT <br />$1.000.000 <br />ANYPROPRIETORIPARTNERIEXECUTIVE <br />OFFICERIMEMBEREXCWDED1 ❑ <br />NIA <br />E.L. DISEASE - EA EMPLOYE <br />$1,000,000 <br />(Mandatory in NH) <br />If yes, describe under <br />E.L. DISEASE -POLICY LIMIT <br />$1,000.000 <br />DESCRIPTION OF OPERATIONS below <br />E <br />F <br />Property <br />Excess Liability <br />ZMD0119116-06 <br />CO23701-007 <br />1/1/2022 <br />1/1/2022 <br />1/1/2023 <br />1/1/2023 <br />SEE BELOW <br />$1 OM Each Occurrence <br />$1 OM Aggregate <br />DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be 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 1/112022-11112023 - <br />$500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon <br />See Attached... <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, <br />NOTICE WILL <br />BE DELIVERED IN <br />CITY OF SANTA ANA <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Risk Management Division <br />20 CIVIC CENTER PLAZA <br />AUTHORIZED REPRESENTATIVE <br />SANTA ANA CA 92702 <br />is <br />RNk"W�"'WLL <br />i4�y-^1x�P <br />REMEl17m6APPROVED11Y: <br />©1988-2015 ACORD C <br />ACORD 25 (2016/03) <br />The ACORD name and logo are registered marks of ACORD <br />'' <br />Rok Managenxnt analyst <br />