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1/b/LVV~ ~l~lb Yl•1 YHVG <br />J/ <br />1~ QA UGi V Gi <br />OTHER RELATED PERSON <br />CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE <br />THROUGH MUTUAL PROTECTION TRUST (MPT) <br />r ax Server <br />Name of Worker Randolph Jones, MD <br />Type of Worker Other Related Persons <br />Employed by or related to the practice of MPT Member or MPT Entity: <br />John G Alevizos DO Inc <br />Membership # or Entity #: 901 <br />Effective Date: August 15, 2008 through December 31, 2009 <br />DBA(s): East Edinger Industrial Urgent Care <br />Tustin-Irvine Medical Group Inc <br />MPT will provide to the above-named Worker, the Claims defense and Claims payment services <br />described in Article VIII of the MPT Agreement, subject to all terms, conditions, and exclusions therein, <br />and subject to payment of all obligations required thereby, for any Occurrence, upon which the Claim is <br />based, arising on or after the above-mentioned Effective Date, in the conduct of Professional Services <br />by such Worker, provided that such Worker was acting within the course and scope of his or her duties <br />and licensure as an actual employee of such Member or Entity at the time of the Occurrence. <br />This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection <br />services as between MPT and the above-named Worker and does not afford membership in the <br />Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional <br />Liability Coverage does not amend, extend or alter the professional Fiability protection services afforded <br />by the MPT Agreement to the above-named Member or Entity. Notwithstanding any requirement, term <br />or condition of any contract or other document with respect to which this Certificate of Professional <br />Liability Coverage may be issued or pertain, the professional liability protection services afforded by the <br />MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT <br />Agreement. <br />The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of <br />liability is shared with the MPT Member. <br />A shared limit of liability means that the MPT Member shares his/her limit of liability with the Worker for any Occurrence upon which <br />a Claim against the MPT Member and the Worker is based. <br />This Certificate shall remain in force unless cancelled or amended by MPT, the MPT Member or the <br />MPT Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the <br />MPT Agreement. <br />MPT does not track Claims asserted against employees or other related persons. <br />The above-named MPT Member or MPT Entity is responsible for notifying MPT and all recipients <br />of this Certificate of Professional Liability Coverage in the event of the termination of the <br />employment of or other relationship with the above-named Worker. Such Member or Entity is <br />also responsible for notifying all recipients of this Certificate of Professional Liability Coverage <br />in the event that any term of this Certificate of Professional Liability Coverage is modified. <br />____. <br />- _ _ __ __ <br />Date: January 6, 2009 <br />PRO ~ ~,~ a ~ r: ~3 <br />V i.:z~ %t.;~ g <br />~~ Laura Stitt Shec-d <br />Assistant C:ily ~~rt`?r:~e1 <br />MUTUAL PROTECTION TRUST <br />~~~~ <br />ey <br />Hammon P. Acuna <br />Vice President, Membership Services <br />