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PROFESSIONAL UNDERWRITERS <br />LIABILITY INSURANCE COMPANY <br />A TOC Company <br />'1888 Century Park E, Ste. 850, Los Angeles, California 90067-'1737 <br />CERTIFICATE OF INSURANCE <br />This is to certify that the Policy of Insurance listed below has been issued to the Insured Named and is In force at this time. <br />Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate <br />may be Issued or may pertain, the insurance afforded by the Policy described herein is subject to all the terms, exclusions <br />and conditions of such Policy. <br />NAME AND ADDRESS OF <br />NAMED INSURED: SPECIALTY: <br />Luis E. Rivera, M_D. General Surgery <br />800 North Tustin Avenue, Suite A <br />Santa Ana, CA 92705 <br />ADDITIONAL INSUREDS: <br />(shared limits of coverage) <br />East Edinger Industrial Urgent Care <br />POLICY NUMBER: <br />P93605-12 <br />LIMITS OF LIABILITY: <br />$1,000,000.00 per claim <br />$3,000,000.00 aggregate <br />RETROACTIVE SPECIALTY: <br />DATE: <br />02/02/2009 <br />POLICY EFFECTIVE DATE: <br />September 1, 2011 <br />72:07 e.m. standard Ume <br />TYPE OF INSURANCE: MEDICAL PROFESSIONAL LIABILITY <br />POLICY EXPIRATION DATE: <br />September 1, 2012 <br />72:07 a.m. standard time <br />POLICY RETROACTIVE DATE: <br />September 1, 2005 <br />72:07 e.m. standard Ume <br />NAME AND ADDRESS OF NAME AND ADDRESS OF BROKER: <br />CERTIFICATE HOLDER: <br />Coastal Community Hospilat Doctors' Company Insurance Services - Celifomla <br />2707 S. Bristol Stree[ 785 Greenwood Road <br />Santa Ane, CA 92704 Nape, CA 94558-0900 <br />Attn: Medical Staff Office <br />Date Issued: August 37, 2011 Authorized Representative: <br />,??,t?YZt7V ?I? hS "7?0 FORM <br />_ii:ra ?_---_--- <br />->?? tit:?i Si. ?Y <br />???,:vt-.:;:: City fi1.LprilCl