CONCENTRA MEDICAL CENTER dba OCCUPATIONAL HEALTH CENTERS OF CALIFORNIA (2)

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ACC)REF 4%� AGENCY CUSTOMER ID: CONCGRO-01 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMEDINSURED The Graham Company Occupational Health Centers of California, A Medical Corporation d/b/a Concentra, Inc. 4714 Gettysburg Rd. POLICY NUMBER Mechanicsburg PA 17055 CARRIER NAIL CODE EFFECTIVE GATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244600-8; Effective 11112022-1/112023 - Each Medical Incidenf/$1,500,000 Aggregate Per Insured or Surgeon IA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-8; Effective 1/112022-11112023 - Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon CA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-8; Effective 1/l/2022-1/1/2023 - Each Medical Incident/$1,000,000 Aggregate Per Insured or Surgeon VANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-8; 1/1 /2022-1/l /2023 - Each Medical Incidenf/$1,500,000 Aggregate Per Insured or Surgeon 3IN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE- Continental Casualty Company - Policy #HAZ 4032244659-8; 1/l/2022-1/1/2023 - 0 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon IY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions. 'S COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Liberty Mutual Insurance Corp. - Policy )-510199-311: Effective: 10/1/2020-4/l/2022 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Insurance Corp. - Policy #WA7-63D-510199-401; Effective: 1011/2020-4/112022 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Mutual Insurance Corp. - Policy #WC5-631-510199-251 (WI); Effective: 101112020-411 /2022 WORKERS COMPENSATION POLICIES: of Arkansas — Liberty Insurance Corp. - Policy #WC7-631-510199-281; Effective: 101112020-41112022 of Southwest (AZ/UT) — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-241; Effective: 101112020-4/112022 of Delaware — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-331; Effective: 1011 /2020-01112022 of Georgia/Hawaii — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-381; Effective: 10/l/2020-4/1/2022 of Illinois — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-411; Effective: 10/112020-4/112022 of Louisiana — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-291; Effective: 101112020-411/2022 of Michigan — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-271; Effective: 10/112020-4/112022 of Nebraska — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-371; Effective: 10/112020-411/2022 of New Jersey — Liberty Mutual Fire Insurance Company - Policy #WC2-631510199-261; Effective: 10/l/2020-4/1/2022 of North Carolina — Liberty Insurance Corp. - Policy #WC7-631-510199-341; Effective: 1011/2020-4/l/2022 of Southwest (KS) — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-421; Effective: 101112020-411/2022 ipy Centers of Southwest I, PA (OR) - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-391; Effective: 10/l/2020-4/l/2022 ipy Centers of South Carolina, PA - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-301; Effective: 10/l/2020-4/l/2022 of Minnesota - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-451; Effective: 1011/2020-4/112022 of Alaska - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-441; Effective: 10/1/2020-4/l/2022 LIABILITY - AIG Specialty Insurance Company - Policy #01-613-93-03: Effective: 9125/2021-9125/2022 - Limit: $10,000,000 :CESS CYBER LIABILITY - Endurance American Specialty Insurance Company - Policy #NVX30011525100; Effective: 9/2512021-9/2512022 - Limit: 0,000,000 Excess of $10,000,000 iverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured, but only for professional services rformed for or on behalf of the above Named Insured. :: OHC OF CA/CMC HAS AN AGREEMENT UNDER # A-2019-006 TO PROVIDE MEDICAL SERVICES TO THE EMPLOYEES OF THE NAMED CLIENT. TY OF SANTA ANA, ITS OFFICERS, AGENTS, VOLUNTEERS AND EMPLOYEES are all included as additional insureds on the above General Liability, to Liability and Umbrella Liability Policies and coverage shall apply on a Primary and Non -Contributory basis if required by written contract. or to loss, and if required by written contract, Waiver of Subrogation is provided on General Liability, Auto Liability, Umbrella Liability and Workers mpensation Policies for work performed under contract if permissible by state law. ACORD 101 (2008101) The ACORD name and logo are registered marks of ACORD RIA MOug>amnt Divislun or •:°"'"ma's /rREvIEwFn& APPR.OsvED By. I rM[.w.iA.t R. V�tGi�Ll � Risk A1anagenxnl Analyst