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ACIORa, CERTIFICATE OF LIABILITY INSURANCE 1 011/05/2014 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(les) 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 lieu of such endorsement(s). PRODUCER C NTA T NAME: David Carothers c/o Praxiom Risk Management, LLC 123 West Bloomingdale Avenue #300 PHONE FAX AND, No Ext: fCNo: E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Brandon, FL 33511 INSURERA: Zurich -American Insurance Company 16535 COMMERCIAL GENERAL LIABILITY INSURED INSURER B Professional Employer Services, Inc. Labor Contractor, for leased workers to: GaryA Linnemann MD Inc dba: Pacific Medical Clinic 1301 S. Vista Ave Suite 207 INSURER C PRAMAGE To EMISES Eaeccurrene�' $ p cis INSURER D CLAIMS-MADE1:1 OCCUR INSURER E : LTi Boise, ID 83705 INSURER F: "' CD f3 MED EXP (Any one person) $ COVERAGES CERTIFICATE NUMBER: 141DO03861209 REVISION NUMREl7S THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOV K THEIRPUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH.. ,ECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJt.� 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 INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIVYYY U - LIMITS GENERAL LIABILITY EACH OCCURRENCE—'^^ $ e COMMERCIAL GENERAL LIABILITY I PRAMAGE To EMISES Eaeccurrene�' $ p CLAIMS-MADE1:1 OCCUR MED EXP (Any one person) $ PERSONALSADV NJURY $ GENERAL AGGREGATE $ GENLAGGREGATE LIMITAPPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY D PEI LOC $ AUTOMOBILE LIABILITY Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Peraccident NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICERIMEMBER EXCLUDED? F-1 (Mandatory in NH) N/A WC 57-19-588-00 02/08/2014 02/01/2015 X WCSLATU- OTH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE s 1,000,000 If yes, d c nbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 Location Coverage Period: 02/08/2014 02/01/2015 Client# 841007 -CA DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD Hat, Additional Remarks Schedule, if more space is required) Gary Linnemann MD Inc dba: Pacific Medical Clinic A /1 1 Coverage is provided for only those employees 1534 E Warner Ave Ste A leased to but not Santa Ana, CA 92705 subcontractors of. CERTIFICATE HOLDER CANCELLATION I City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 Civic Center Plaza THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Santa Ana, CA 92702 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD (4 3L\