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06~~26/2007 16:43 2413390 <br />u ~~vc. duuc fu. ~w acv»c~o•», ~..wn <br />PRO~S$IbNaL UNDERWRITERS <br />LIABILITY INSURANCE CpMPANY <br />_ A TDG Company <br />12'127 W lahiro Boulevard, Suil® 601 Lbe Anpgiee, Califomta 90D25 <br />CERTIFICATE OF INSURANCE <br />PAGE 02/04 <br /> <br />This is b certify that the Policy of Insurancalhbed DtWw has been issued to the Insured Namod arld p In fine atthlstime. <br />Notllathatending any nOquiremam, term o.° candl'GOn of any contreetorother dnOUmeM wim reepesk to whbh Mtie K'.ertMloe9e <br />may be 1:wed or msY pertain, the Insurance afforded by the Pmllry deecdbed herein m subject m MII are tennis, erclutlons <br />and condflipn6 Cf such Polity. <br />NAME AND AODRE88 OF <br />NAMEfl INSUREb: <br />Luis E. Rivera, M.D. <br />2222 S, Main Sheet <br />Santa Ane, CA 92787 <br />ADDITIONAL INSURFAS: <br />(shares limits d naveragr} <br />POLICY NUMBkR: <br />Pt388QStl7 <br />LIMITS OF LUIBILITY: <br />S1,DQ0,000.00 Per ckllm <br />y8,000,pOp.DO a99regahs <br />SPECWLTY: <br />QccupBgonal Medians - No Surgery <br />POLICY EFFECTNE DATE; PIOI.ICY E7tAIRATION DATrr <br />3eplgmt+er t, 2D0B Seplertlber 1, 2007 <br />t2:Ot sm. sprs4rd ane 72~it am. slsm4td ans <br />POLICY RETROACTIVE O14TE <br />September t, 2f105 <br />171• H II.Ie. '~trnlhlM'i111N <br />TYPE 4F INSURANCE: M6pCAL PROFESSIONAL LIABILITY <br />NAME AND ADDRESS OF <br />CERTIFICATE HOLDER: <br />Luis E. Rwere, M. D. <br />Dete Issued: Bepmmber B, 2CpB <br />NAME AND ADDRF~9 ~Of BROKER: <br />R01 IssunRCe80rvices <br />25241 9eu S P01111! Drive <br />Lspuns HYIe. GAa28~ <br />Autnadzud Represenwmre: ~A'R°~~,~~, <br />n , •,4 <br />~,.,. <br />__._._ <br />?1s~is[an: ~:ity f~ttorscy <br />