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<br />AC40RD, CERTIFICATE OF LIABILITY INSURANCE
<br />8DATE
<br />/28/2015Dmvv)
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />InterWest Insurance Services
<br />License #0601094
<br />Court Street
<br />coNTACT Michelle Goodwin CIC, CISR, CPSR
<br />NAME:
<br />PHONE 831-635-2247 FAXl. . 831-638-6801
<br />. mgoodwin@iwins.com
<br />M:�ggoodwin@iwins.com
<br />INSURERS AFFORDING COVERAGE
<br />NAIC 0
<br />Woodland CA 95695
<br />INSURER A: Liberty Mutual Fire Ins Co
<br />23035
<br />MED EXP (Any one person) $10,000
<br />INSURED USHEA-1
<br />INSURER B:Liberty Insurance Corporation
<br />42404
<br />U.S. Healthworks Holding Company, Inc.
<br />INSURER C:Safety National Casualty Corp15105
<br />$
<br />25124 Springfield Ct., Ste 270
<br />Valencia CA 91355
<br />INSURER D
<br />AS2691450294045
<br />9/1/2015
<br />INSURER E:
<br />COMBINED SINGLE LIMIT
<br />Ea accident $1,000,000
<br />INSURER F
<br />BODILY INJURY (Per accldent) $
<br />PROPERTY DAMAGE $
<br />Per accident
<br />COVERAGES CERTIFICATE NUMBER: 863365504 REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR
<br />LTR
<br />rypE OF INSURANCEADDLSUBR
<br />INSD
<br />MI
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMDD VY
<br />POLICY EXP
<br />MMDD YYY
<br />LIMITS
<br />A
<br />X I COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE X1 OCCUR
<br />Y
<br />TB2691450294035
<br />9/1/2015
<br />9/1/2016
<br />EACH OCCURRENCE $1,000,000
<br />DAMAGE TO FED
<br />PREMISES (EaEoccurrence) $1,000,000
<br />MED EXP (Any one person) $10,000
<br />PERSONAL &ACV INJURY $1,000,000
<br />GENT AGGREGATE LIMIT APPLIES PER:
<br />POLICY E PRO-
<br />JECT M LOC
<br />OTHER:
<br />GENERAL AGGREGATE $2,000,000
<br />PRODUCTS - COMP/OP ADD $2,000,000
<br />$
<br />A
<br />AUTOMOBILE LIABILITY
<br />X ANY AUTO
<br />ALL OWNED SCHEDULED
<br />TOS
<br />X HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />AS2691450294045
<br />9/1/2015
<br />9/1/2016
<br />COMBINED SINGLE LIMIT
<br />Ea accident $1,000,000
<br />BODILY INJURY (Per person) $
<br />BODILY INJURY (Per accldent) $
<br />PROPERTY DAMAGE $
<br />Per accident
<br />B
<br />X
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />TH7691450294055
<br />9/1/2015
<br />9/1/2016
<br />EACH OCCURRENCE $25,000,000
<br />AGGREGATE $25,000,000
<br />DED X RETENTION 10,000
<br />$
<br />Q
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />OPFICER/MEMBEER EXCLUDER] F-1
<br />(Mandatory In NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />LDC4042721
<br />9/1/2015
<br />/1/2016
<br />I
<br />PER PER (H-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT $2,000,000
<br />E.L. DISEASE - EA EMPLOYEE $2,000,000
<br />E.L. DISEASE -POLICY LIMIT $2,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AC ORD 101, Additional Remarks Schedule, may be attached If more space Is required)
<br />Certificate holder is included as additional insured as required by written contract per the attached endorsement
<br />Re: 1619 East Edinger, Santa Ana, CA 92705
<br />CERTIFICATE HOLDER CANCELLATION '10 days notice for non payment
<br />ACORD 25 (2014/01)
<br />@ 1988.2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
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<br />0'3
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana
<br />ACCORDANCE WITH THE POLICY PROVISIONS,
<br />20 Civic Center Plaza
<br />Santa Ana CA 92701
<br />AUTHORIZED REPRESENTATIVE
<br />r
<br />ACORD 25 (2014/01)
<br />@ 1988.2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
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