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A,UK)iRbr CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) TYPE OF INSURANCE 07/05/2013 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 lieu of such endorsements s . PRODUCER Advanced Risk Solutions CONTACT NAME: PHONE A/C, No Ext : FAX A/C No 12980 Metcalf Suite 490 Overland Park KS, 66213 E- MAILADDRESS: LIABILITY INSURERS AFFORDING COVERAGE NAIC# INSURER A: Lumbermen's Underwriting Alliance 23108 w advancedrisksolutiors.com INSURED Employers Resource Management Co. For: Pacific Medical Clinic INSURER B: INSURER c: COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑OCCUR INSURER D: 1534 E Warner Ave Ste A Santa Ana, CA 92705 INSURER E: INSURER F: $ XXXXXX COVERAGES CERTIFICATE NUMBER: REVISION NUMBER' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. IN R LTR TYPE OF INSURANCE ADD'L INSRD SIT WVO POLICY NUMBER POLICY EFF MM/DD POLICY EXP MMIDDM^rV LIMITS GENERAL LIABILITY Not Applicable EACH OCCURRENCE $ XX)O(XX COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑OCCUR DAMAGE TO RENTED PREMISES Ea occurrence ) $ XXXXXX MED EXP(Anyone person) $ XXXXXX PERSONAL &ADV INJURY $ XXXXXX GENERALAGGREGATE $ XXXXXX GEKL AGGREGATE LIMIT APPLIES PER POLICY PRO- ECT LOC PRODUCTS - COMP /OPAGG $ XXXXXX XX $ XXXX AUTOMOBILE LIABILITY A AUTO ALLL L OWNED SCHEDULED Not Applicable k S N COMBINED SIN ELIMI Ea accident $ XXXXXX BODILY INJURY (Per person) $ XXX XXX BODILY INJURY (Per acclderr $ X)(XXXX AUTOS AUT05 HIRED AUTOS NON -OWNED AUTOS .p \� CCU"' "�`�� a o'Coo PROPERTY DAMAGE Peraccident $ XX)(XXX $ once 00 $ UMBRELLA LIAB OCCUR Not Applicalb NOV EACH OCURRENCE $ XXXXXX AGGREGATE $ )()()(X')(X EXCESS LIAB CLAIMS MADE 1'� DED RETENTION $ $ XXXXXX $ XXXXXX $ XXXXXX A WO COMPE S T N AND EMPLOYERS' LIABILITTY ANY PROPRIETOWPARTNER/EXECUTIVIE 429069 07/01/2013 07/01/2014 OTH- X WCSTA ITS ER E.L. EACH ACCIDENT $ 1,000.000.00 OFFICERIMEMBER EXCLUDED? YIN NIA (Mandatory in NH) ❑ If yes, describe under E.L. DISEASEEA EMPLOYEE $ 11000,000.00 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Addltlonal Remarks, Schedule, if more space is required) THIS CERTIFICATE CONFERS NO ADDITIONAL INSURED RIGHTS UPON THE CERTIFICATE HOLDER. Only the co- employees of Pacific Medical Clinic, 1534 E Warner Ave Ste A, Santa Ana, CA 92705 but not subcontractors of: Pacific Medical Clinic CERTIFICATE HOLDER 040695 CANCELLATION City of Santa Ana 20 Civic Center Plaza Santa Ana CA, 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Robert Gagne !t� T ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD