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<br />1
<br />
<br />ACORD..
<br />
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />
<br />DATE (MMIDD/YYYV)
<br />
<br />3/24/2005
<br />
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
<br />ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
<br />HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
<br />ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
<br />
<br />PRODUCER
<br />Arthur J. Gallagher & Co.
<br />License #0726293
<br />505 North Brand Blvd. Suite 600
<br />Glendale, CA 91203-3944
<br />Phone: 818-539-2300 Fax: 818-539-2301
<br />------
<br />INSURED A - .AvO:L- -- '~J7
<br />u.s. HealthWorks. Inc.
<br />3655 North Point Parkway, Suite 150 A - "'co 3- dJ.7
<br />A- ,:7,OO'I-I;)D -0/) CJ.-
<br />
<br />(+- J.w5- 1<1.),
<br />
<br />INSURERS AFFORDING COVERAGE
<br />
<br />, NAIC#
<br />1._ 29424
<br />19682
<br />40258
<br />37478
<br />
<br />Alpharetta, GA 30005
<br />
<br />,_I_N.S~RERA: Hartford Casual!y.II}.s:urance Company
<br />INSURER 8: H<:ir:!!.ord Fire Insurance CO~P5~I}Y
<br />INSURER c: Americ~!:! In!ernational South lnsuran~~ C_o_r:!1pany
<br />INSURER 0 Hartford Insura~~~ q.ompany of the Midwest
<br />
<br />INSURER E:
<br />
<br />COVERAGES
<br />
<br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
<br />ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
<br /> MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
<br /> POliCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />-lr1:-r..~D' POLICY NUMBER P~..t+~~ri~F6g;U~E POLICY EXPIRATION LIMITS
<br /> A
<br />A I ~ERAL LIABILITY ! 72UENUM8309 I 09/01/04 ! 09/01/05 ~~JURRENCE__ $ 1,000,000
<br /> OAMA E TORENrED
<br /> _~, _c:OMMERCIALGENERALLlABILlTY ~~~l,sES (Ea,Q9cureflce $ 300,000
<br /> , -1 CLAIMS MADE ~ X j OCCUR: ~_~~_P(Any()n!,person) $ 10,000
<br /> ]~ "
<br /> >--- -- ~~SQNAL & ADV INJURY $ 1,000.000
<br /> '" GENERAL AGGREGATE $ 3,000,000
<br /> i~'~AGGR~GATE LIMIT AP~_I PER: PRODUCTS - COMP/OP AGG $ 3.000,000
<br /> POLICY I ! ~~.fl;: X LOC - -
<br />B ~IOMOBILE LIABILITY 72UENUM8309 09/01/04 09/01/05 COMBINED SINGLE LIMIT
<br /> , j$ 1,000,000
<br /> _; ANY AUTO (Eaaccident)
<br /> -------
<br /> - ALL OWNED AUTOS i BODILY INJURY
<br /> $
<br /> X SCHEDULED AUTOS ~,)\.;.D AS TO FORM (Per person)
<br /> -\ ,,- -
<br /> X HIRED AUTOS ! BODILY INJURY
<br /> , $
<br /> c-"- NON-OWNED AUTOS , j,C::Y; , l (Per accident)
<br /> r .?rl~( .0 rof:, J I 2_ - -- -I --
<br /> -- PROPERTY DAMAGE $
<br /> '"'i"" ~~-_7,Z,,,_, (Peraccidenl)
<br /> ! ~RAGE LIABILITY Assist nt Cit~f'.\unr 1'-." AUTO ONLY - EA ACCIDENT $
<br /> f---- ANY AUTO OTHER THAN EAACC $
<br /> ! I AUTO ONLY. AGG $
<br />C ~ESS/UMBRELLALlABILlTY BE2681205 09/01/04 09/01/05 EACH OCCURRENCE _L__ 15,OOO..QQQ
<br /> -----
<br /> X OCCUR C CLAIMS MADE AGGREGATE $ 15,000.000
<br /> , ---- --- --
<br /> i ----- ---- --'---
<br /> ~ DEDUCr'BlE ! $
<br /> X RETENTION $10000 ~ $
<br />D WORKERS COMPENSATION AND 72WNMG3070 09/01/04 09/01/05 X I T~~$I~JI~S I I OJ~.
<br /> EMPLOYERS' LIABILITY 1,000,000
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
<br /> OFFICE R/MEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE $ 1,000,000
<br /> ~~E~~LP~OVIS4oNS below EL DISEASE - POLICY LIMIT $ 1.000.000
<br /> OTHER i
<br /> ,
<br /> ,
<br /> ,
<br />DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
<br />*Except 10 days notice for non-payment of premium. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its officers, employees,
<br />agents, volunteers and representatives are named as additional insureds with regard to liability and defense of suits arising from the operations and uses
<br />performed by or on behalf of the named insured.
<br />
<br />CERTIFICATE HOLDER
<br />
<br />CANCELLATION
<br />
<br />City of Santa Ana
<br />City of Santa Ana Fire Department
<br />
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
<br />DATE THEREOF, THE ISSUING INSURER WILL ~AIL ~ DAYS WRITTEN
<br />NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ~~.lSO<.B"lU:lO<
<br />JMP:llI~DA6tlOUfXIlI~~)((BXOlWDOl3:;oR(
<br />~
<br />AUTHORIZED REPRESE NT A TIVE
<br />
<br />c:::::- 'li 'I. _'I.
<br />---==:>c~ ~ """...:-..~--
<br />@ ACORD CORPORATION 1988
<br />
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92701
<br />
<br />ACORD 25 (2001/08)
<br />
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