TUSTIN-IRVINE MEDICAL GROUP 1A-2010

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07/14/2010 10.32 FAX 714 836 3087 TIMG TUSTIN Fax Server 1/4/2010 4:'52:05 PM PAGE 3/003 Fax Server OTHER RELATED PHYSICIAN CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker Rsndolph Jonas, MO Type of Worker. Other Related Physician Employed by or related to the practice of MPT Member or MRT Entity: John O Alevlzoa DO Inc Membership 0 or Entity d: 901 Effective Date: August,15, 2009 thpeugh 13sq, "ber 91, 2010 DBA(s): East,Edinger Industrial Urgent Oars Tustin-Irvine Meit11ci1 Group, MPT will provide lo the above-named Worker, the Claims defense and Claims payment services described in Part 1 of the MPT Agreement subject to all terms, conditions, and exclusions therein, and subject to payment of al obloa ions required thereby, for any Occurrence, upon which the Claim is based, arising on or after the above-mentioned Effective Dade, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the-course and scope of his or her duties and licensure as an actual employee of such Member or Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above-named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to Such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the profestior al. liability protection services afforded by the MPT Agreement to the above-named MornWr-or Entity..Nottuithsolli tg any requirement, term or condition of any contract or other document %6th respect lo:-Olch this Certificate of Professional Liability Coverage may be issued or pertain, the professional liilb„B,ity protection services afforded by the MPT Agreement described herein are subject to all terms, condii ions, and exclusions of the MPT Agreement. The limit of liability through MPT Is $1 Million per Occurrsnce43 Million Aggregate. Such limit of liability Is shared with the MPT Member. A snared Cantle of l 0100 l means that the AWY Member eh W hiafher limit of liability wRh the Worker for any Oocurrenoo upon welch a Claim against the MPT Member and eta Mlorlaw is b"O. ' - , This Certificate shell remain In force unless canceled or amended by MPT, the MPT Member or the MPT Entity. This Certificate of Professional Liability Coverage is;incorporatod by this reference into the MPT Agreement. MPT does not track Claims asserted against employees oG Other Relab O Rhysicians. The above-named MPT Member or MPT Entity is respoilhtibie for notifying MPT and afi recipients of this Certificate of Professlonst Liability Coverage to that event of the termination of the employment of or other relationship with the above-non?d Mbrkw. Such Member or Entity Is also responsible for notllying all recipients of this Certificate of Prlofeswonal Liability Coverage In the event that any berm of this CertMate of Professional Liability Coverage In modified. Date. January4, 2010 MUTUAL PROTECTION TRUST , mammon P, Acur e .Vice Presidertti,Membership SerVIM 2 003/004