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??RD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Ileu of such endorsement(s). PRODUCER Advanced Risk Solutions CONTACT NAME: 92980 Metcalf, Suite 490 _ _ __ _ Overland Park, KS 66293 PHOr±g 1A[?r.?•-En'I?-_ --- nic N°j=- - EJuIAIL ADDRESS: _ _ _ _ 1_NSU RER(5) AFFORDING COVERAGE NAIC R www.advancedrisksolutions.com _.__"-. ._ ______-_- __._ -..__ _- __ __ INSURER A - um ermen's Underwriting Alliance _ _ - _ ___ INSURED Emplo ers Resource Mana ement Co INSURER B --- -------- ----------- y g . - For: Pacific Medical Clinic wsulxeR c : __- ____ 9 534 East Warner Avenue,#A INSURER D "- - - --- - Santa Ana CA 92705 --- INSURER E : ___ __ INSURER F THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER -- POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYW .___- _. - --- __... ___.__--- LIMITS GENERAL LIABILITY Not Applicable EACH OCCURRENCE __ - $ XXXXXX COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ? ? PREMISES (Ea occurrence __ _ ? ? ? - XXXXXX $___ _ _ ? CLAIMS-MADE ? OGGUR MED EXP (Any one person) $ XXXXXX PERSONAL 8 ADV INJURY $ XXXXXX __ GENERAL AGGREGATE $ XXXXXX ___ __ __ ____ GEN'L AGGREGATE LIMIT APPLIES PER: _ O PRODUCTS -COMP/OP AGG -- - - XXXXXX $ ?- POLICY PRO- LOC I lO $ XXXXXX AUT OMOBILE LIABILITY Not Applicable MBINED SINGLE LIMIT Ea accident $ _ _XXXXXX ANY AUTO ? ?O - BODILY INJURY (Pe person) -,_-, $ XXXXXX _ ALL OWNED SCHEDULED AUTOS AUTOS 1? C? _ t tT ?? e? BODILY INJURY (Pe accitlenl) - -- $ XXXXXX NON-OWNED HIRED AUTOS AUTOS • `- . • r`?? . PROPERTY DAMAGE Per acctlent $ XXXXXX __ _ J ? ? a` . - - sac = ;` - --_-_ _ $ - ---- UMBRELLA LIAR OCCUR Not Applicable EACH OCCURRENCE --' -- $ J(J(j(J(j(J( - EXCESS LIAB GLAIMS-MADE AGGREGATE - $ XXXXXX DED RETENTION $ $ XXXXXX $ XXXXXX $ XXXXXX A WORKERS COMPENSATION 424506 7/f /2012 7/9/2013 WC STATU- OTM AND EMPLOYERS' LIABILITY Y / N TORY LIMITS - _E_R_ _ ANY PROPRIETOR/PARTNER/EXECUTI V E OFFICER/MEMBER EXCLUDED? ? N / A E.L. EACH ACCIDENT _____ $ 1,000,000 (Mandatory In NH) es escnbe untler E.L. DISEASE - EA EMPLOYEE $ _1 00? QQQ y , DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ ? ,000,QQ() DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach AC ORO 101, Additional Remarks Schedule, if more space Is requlretl) THIS CERTIFICATE CONFERS NO ADDITIONAL INSURED RIGHTS UPON THE CERTIFICATE HOLDER. Only the co-employees of Pacific Medical Clinic ? 534 East Warner Avenue,#A Santa Ana CA 92705, but not subcontractors of: Pacific Medical Clinic Waiver of subrogation applies for workers' compensation in favor of City of Santa Ana SPEC 04-042 CERTIFICATE HOLDER CANCELLATION 040695 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Purchasing Division M-96 ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza Santa Ana CA 92702 AUTHORIZED REPRESENTATIVE y?/? ?J/ ?i T / Robert M Ga ne ©'1988-20'10 ACORD CORPORATION. All rights reserved. ACORD 25 (20'10/05) The ACORD name and logo are registered marks of ACORD CLI(1 NU 133S021S .]ill NP.V ti/1S/2012 B'90.00 LM L?.3ge? l of 1