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76/20/2024
<br />(MM/DD/YYYY)
<br />,a`oRo° CERTIFICATE OF LIABILITY INSURANCE
<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 endor ement s .
<br />PRODUCER CONTACT
<br />Graham Company,PHONE °rce ra I
<br />a Marsh & McLennan A n LL co a A/c No Ex _1-15 - 5
<br />E-MAIL
<br />One Penn Square Wes ADDRESS: )ncentra_Unit@grahamco.com
<br />Philadelphia PA 1910 Eg(s)4%pwwPawgAr% A,—,-.. sows
<br />INSURERA C 'UALIA suJtyUrn pa I%. I A %_0 V U9A
<br />INSURED CONCGRO-01 INSURER Llbt `Y Mutual Fire Ins. Co. 23035
<br />Occupational Health Centers of California, URE c : Libe n p ra �
<br />A Medical Corporation, c/ elect Medical Corporat
<br />dba Concentra Medical rs OF .RD: Allie w
<br />4716 Old Gettysburg Ro - ployers Insura-- ^f tMausau 21458
<br />Mechanicsburg PA 170 P\/P u RF: I C 3 00
<br />COVERAGES N IL CIF N ER:, 16 V U*R
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELL ✓V H ,dE BEEN ISSUED O T7ETN7URED NAMED ABOVE FOR THE PO ICY ERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR COS -)IT' ,N 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 />I
<br />SUBR
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DD/YYYY
<br />POLICY EXP
<br />MM/DDIYYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />Y
<br />HAZ4032244581-8
<br />1/1/2024
<br />1/1/2025
<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 />$1 M Claim/$3M Ag
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$3,000,000
<br />POLICY ❑ PRO ❑
<br />JECT LOC
<br />X
<br />PRODUCTS - COMP/OP AGG
<br />$ 3,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />Y
<br />Y
<br />AS2-631-510199-324
<br />4/1/2024
<br />4/1/2025
<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 />1/1/2024
<br />1/1/2025
<br />EACH OCCURRENCE
<br />$9,000,000
<br />AGGREGATE
<br />$ 10,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED X RETENTION $
<br />$
<br />C
<br />F
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />Y
<br />WA7-63D-510199-354
<br />WA5-63D-510199-314
<br />4/1/2024
<br />4/1/2024
<br />4/1/2025
<br />4/1/2025
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />OFFICER/MEMBER EXCLUDED? ❑
<br />NIA
<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 />YAC-L9L-477341-014
<br />1/1/2024
<br />1/1/2025
<br />SEE BELOW
<br />D
<br />Excess Liability
<br />CO23701-009
<br />1/1/2024
<br />1/1/2025
<br />$10M Each Occurrence
<br />$10M Aggregate
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />PRIMARY LIABILTY POLICY includes General Liability Coverage on an Occurrence Basis and Professional Liability Coverage on a Claims Made Basis.
<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 />INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-10; Effective 1/1/2024-1/1/2025 -
<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. NOTICF WILL FIF DELIVERED IN
<br />CITY OF SANTA ANA ACCORDANCE WITH THE POLICY PRC
<br />Risk Management Division a „.° "F RUManagernenfDMsian
<br />20 CIVIC CENTER PLAZA AUTHORIZED FPRESENTATIVE REVIEWED &APPROVED BY.
<br />SANTA ANA CA 92702 4g;e Aecv44
<br />® Risk Management Specialist
<br />@ 1988-2015 ACORD
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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