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HomeMy WebLinkAboutSUNRISE MULTISPECIALIST MEDICAL CENTERINSURANCE ON FILE WORK MAY PROCEED N-2020-084 UNTIL INSURANCE EXPIRES p5 /1M/1010 CLERK OF COUNCIL DATE: AGREEMENT FOR MEDICAL SERVICES AND TESTING 0;,tmpr 5ahl,14, 1"wb24 d�THIS AGREEMENT is made and entered into this 14th day of February, 2020 by and between William H. Nuesse, M.D. and Mary Ann Nesse, D.O., a California medical corporation, doing business as Tifrt @c Multispecialist Medical Center ("Consultant"), and the City of Santa Ana, a charter city and m11716ipal corporation organized and existing under the Constitution and laws of the State of California rn (..City"). IV No RECITALS cm A. City desires to retain a consultant to provide non -industrial medical services including but not limited to Department ofTransportation ("DOT") mandated services, drug tests, respiratory fitness tests, vision testing, post -accident testing, pre -employment examinations, fitness for duty . examinations, and similar medical services for employees or applicants for employment. B. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional firm in the field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: I. SCOPE OF SERVICES A. Consultant shall perform medical services including examinations and testing for non- industrial medical services including but not limited to Department of Transportation ("DOT'l mandated services, post -accident testing, pre -employment examinations, fitness for duty examinations, and similar medical services for employees or applicants for employment. Each service request will be confirmed in writing between City's Human Resources Department and Consultant prior to Consultant providing services pursuant to this Agreement. Specifically, consultant's services will include: I ) For prospective and current City employees to perform the duties of the position for which they are being considered (pre -employment assessments), using pre- determined medical protocols for each job classification; such protocols may be modified by the physician, in consultation with the City's Executive Director of Human Resources, or his/her designee, as is necessary to make a determination as to suitability for employment; 2) For current City employees being considered for employment in Department of Transportation (DOT) and non -DOT positions requiring pre -placement or pre - assignment drug screens; 3) Fitness for Duty examinations (industrial and non -industrial), and provide reports and recommendations regarding the suitability of current employees to continue to perform their duties; 4) Urine and breath specimen collection, laboratory analysis and Medical Review Officer (MRO) responsibilities; 5) Department of Motor Vehicles (DMV) Driver's License physical examinations; 6) DOT -mandated drug and alcohol testing of employees considered 'safety sensitive' as defined under DOT regulations and City policy. Consultant shall ensure all such testing complies with DOT testing procedures as per 49 CFR, Part 40; such testing k5944v1 to include pre -employment and pre -assignment. B. City shall be responsible for the organization, scheduling, and management of DOT and non -DOT "reasonable suspicion" drug and alcohol testing, and DOT "random" and "post - accident" drug and alcohol testing. Consultant shall facilitate evaluation of dip, results of said testing by qualified personnel, in accordance with the provisions of the Agreement and relevant laws and regulations. C. Consultant shall ensure that clinics used for DOT -related drug and alcohol testing maintain a current valid contract with a Substance Abuse and Mental Health Set -vices Administration (SAMSHA)-certified laboratory. Consultant shall ensure turn -around time from specimen collection to obtained test results shall be a maximum of three (3) working days for a negative test, and a maximum of five (5) working days for a positive test. A As part of the medical services review program, Consultant shall: 'I) Analyze current job classification specifications and make recommendations for the City's use in the medical examination and drug testing process. 2) Provide training to Risk Management personnel in administration procedures of Consultant's medical services review process. 3) Communicate with City Risk Management staff regarding applicants' or employees' progress throughout the medical services review process. 4) Communicate directly with applicants and City Risk Management staff throughout the pre -employment or pre -assignment process in regard to results and medical conditions as ascertained through the medical or physical examinations. 5) Provide an electronic final report in a format established by City Risk Management staff at its sole discretion, outlining each candidate's pre -employment placement medical evaluation and results. 6) provide quarterly electronic activity reports, in a format established by Risk Management in its sole discretion, on the nature and number of examinations conducted, including but not limited to results and final dispositions. 7) Provide a detailed quarterly explanation and summary of charges incurred. S) Provide all quarterly and annual summaries as required under the DOT, 9) Provide consultation as needed to Risk Management staff regarding medical services provided and outlined in the Agreement. ]0)Consultant solely shall review all piv-employment/lire-placement medical evaluation services and maintain records, pursuant to the Agreement, in accordance with State and Federal laws, or as otherwise reasonably required by the City, and to the fullest extent pennitted by law. 11) Consultant agrees to permit duly authorized agents and employees of the City to review such records, 12) Consultant shall maintain all books, documents, papers, accounting records, and other evidence pertaining to the fees paid under this Agreement. Consultant will make materials available at their offices at reasonable times and notice, during the period of the Agreement and for three (3) years after date of final payment under the Agreement for inspection by the City or by any other governmental entity or Department participating in the funding of the Agreement, or any authorized agents thereof. 13) Consultant's documents shall not be used, duplicated, or disclosed to any other third party withoirt written permission, unless such disclosure is required by law. Consultant shall not be required to create or maintain books and records not ii5944v1 required in the ordinary course of Consultant's business operations, nor will the Consultant be required to disclose any information, including but not limited to product cost or pricing data, which Consultant considers confidential or proprietary. 14) Any Agreement changes which are mutually agreed upon by and between the parties shall be incorporated in written amendments to the Agreement. 15) If the circumstances on a particular hearing and/or court proceeding warrant the presence of a competent and knowledgeable representative of the Consultant, the City may request and contractor shall provide such representative, at the rates provided in Exhibit A and upon proper HIPAA release. 16) Maintain a network of qualified and trained medical providers and medical specialists for necessary exams; Orient City staff in the legallmedical/risk management and human resources aspects of Consultant services; 17) Communicate directly with applicants to obtain the confidential medical information that is needed for clearance for a particular job; 18) Manage all bill review functions for the medical exams performed by clinics; and, 19) Provide access for City staff to Consultant's tracking system. E. Depending on job classification, pre -employment and pre -assignment medical examination processes may include: job profile review; review of medical history; check vital signs; detailed vision exam, including check ofneadfar/peripheral vision, Ishihara 14 and primary color; audiogram (if classification has specific occupational noise exposure or critical hearing demands); chest x-ray; EKG or treadmill stress EKG; Spirometry; chem panel 20: CBC w/diff; dipstick UA, or UA w/Micro (to lab); venipuncture & collection. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services the rates and charges identified in Exhibit A. The total annual amount authorized under this Agreement shall not exceed forty thousand dollars (S40,000) during the term of this Agreement. b. This Agreement authorizes payment of any services provided by Consultant from January 1, 2020 to the date of this Agreement. C. Payment by City shall be made within forty-five of days (45) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work that fails to meet the standards of performance set forth in the Recitals, which may reasonably be expected by City. 3. TERM This Agreement shall commence on the date written above and terminate on June 30, 2021, unless terminated earlier in accordance with Section 15, below. 4. INDEPENDENT CONSULTANT Consultant shall, during the entire term of this Agreement, be construed to be an independent Consultant and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in #5944vl a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 5. RESERVED 6. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial Genera[ Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, employees, agents, volunteers and representatives as additional insured(s) and shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Consultant's operations in the performance of this Agreement, including, without (imitation, acts involving vehicles. The insurance policy shall not have an exclusion for sexual molestation. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence, with $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insureds provisions. b. Business automobile liability insurance, or equivalent form, with a combined single limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned, hired and non -owned automobiles. C. Worker's Compensation Insurance. In accordance with the California Labor Code, Consultant, if Consultant has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim with $2,000,000 in the aggregate. e. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: (i) Consultant shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. (ii) Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved by the City. (iii) Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. #5944v1 (iv) Consultant shall supply City with a fully executed additional insured endorsement. f. If Consultant fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in forceand paid ibr, the City shall have the right, at the City's election, to terminate this Agreement. Such temrination shal I not affect Consultant's right to be paid for its time anti materials expended prior to notification of termination. Consultant waives the right to receive compensation and agrees to indemnify tine City for any work performed prior to approval of insurance by the City. 7. WDEI1 NIFICATiON Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives front liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Consultant or its, subcontractors, agents, employees, or other persons acting on their behalf which rebates to the services described in section I of this Agreement; and (2) 8'om any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the eventsreferred to in this Section or by reason of the terns of, or effects, arising fi-om this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party challenging the validity of this Agreement, or asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terns of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. Notwithstanding the foregoing, to the extent Consultant Services are subject to Civil Code Section 2782.8, the above indemnity shall be limited, to the extent required by Civil Code Section 2782.8, to claims that arise out of, pertain to, or relate to the negligence, recklessness, or willful misconduct of the Consultant. 8, RECORDS Consultant shall keep records and invoices in connection with the work to be performed under this Agreement. Consultant shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services; expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longerperiod required by law, from the date of filial payment to Consultant under this Agreement. All such records and invoices shall be clearly identifiable. Consultant shall allow a representative of the City to examine, audit, and [Hake transcripts or copies of such records and any other documents created pursuant to this Agreement during regular business hours. Consultant shall allow inspection of all work, data, documents, proceedings, and activities related to this Agreement for a period of three (3) years train the date of final payment to Consultant under this Agreement. 9. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or tt5944v1 disclose such intbrnation except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but !it no event less than reasonable care. "Confidential information" shall include till nonpublic information. Confidential information includes not only written information, but also information tramsforrd orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary andfor agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to ally irmi"ornation that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (c) is independently developed by the Consultant without rererence to information disclosed by the City. 10. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. I1, BACKGROUND CHECK REQUIREMENTS Consultant shall riot assign any employee, agent, subcontractors or volunteer to provide services pursuant to this Agreement, if that employee, agent, subcontractors or volunteer is required to register as a sex offender under California Penal Code Section 290 et seq, has a conviction for ally crime of moral turpitude, has a conviction for a violent felony as defined in California Penal Code Section 667.5(c), or has a conviction for a serious felony as defined in California Penal Corte Section I I92a7(c). Disqualifying convictions include but are not limited to, violations ofCalifornia Penal Code Sections 37, 128,136.1 with Section 186.22, 187,190.190.4 and 192(a), 205, 206, 207-209.5, 211, 212, 212.5, 213, 214, 215, 218-219, 220, 236.1(b) or 236.1(c), 243 A, 261, 261.5, 273.5, 262, 264.1, 266, 266c, 266h, 266i, 266J, 267, 269, 272, 273a, 273ab, 273d, 285, 286, 288, 288a, 288.2, 288.3, 288.4, 288.5, 288.7, 289, 290, 311.1, 311.2, 311.3, 311.4, 311.10, 311.11, 314, 347(a), 368, 417(b), 451(a),518 with 186.22, 647.6, 6530(c), 664 and 187, 667.5(c),18745,18750, or 18755, 12022.53, 11418(b)(1) or (b)(2); Business and Pr%.sslons Code Section 729. Failure to comply with this Section shall be grounds for immediate termination of this Agreement, 12. NOTICE Any notice, tender, demand, delivery, or other- communication pursuant to this Agreement shah be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P:O. Sox 1988 Santa Ana, CA 92702-1988 Fax 714-647-6956 #5944v1 r, With courtesy copies to: Executive Director Human Resources Agency City of Santa Ana 20 Civic Center Plaza (M-34) P.O. Box 1988 Santa Ana, California 92702 And City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.O, Box 1988 Santa Ana, California 92702 Fax 714- 647-6515 To Consultant: William H. Nuesse, M.D. or Mary Ann Nuesse, D.O. Sunrise Multispecialist Medical Center 867 South Tustin Street Orange, California 92866 lax-714-771-6918 A party may change its address by giving notice iu writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 13. CXCLUSIYITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant regarding the subject matter therein, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant. The patties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Consultant or the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein. 14. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior written ff5944v1 consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services, which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 15. TERMINATION Except as otherwise specified herein, this Agreement may be terminated by the City upon thirty (30) days written notice of termination, in such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. As a condition of such payment, the Executive Director may require Consultant to deliver to the City all work product completed as of such date, and in such case, such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b, Payment need not be made for work that fails to meet the standard of performance specified in the Recitals of this Agreement. 16. NONDI[SCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, gender identity, gender expression, gender, medical conditions, genetic information, or military and veteran status, age, national origin; ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization, promotion, termination or other employment related activities or any services provided under this Agreement, Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 17. JURISDICTION -VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, acid enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 18. PROFESSIONAL LICENSES Consultant shall, throughout the tern of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by are laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies, Consultant shall notify the City immediately and in writing of its inability to obtain or maintain such pen -nits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 19. MISCELLANEOUS PROVISIONS it. Each undersigned represents and warrants that its signature herein below has ate power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attortey's fees, for any #5944v I injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. C. The parties agree that this Agreement can be signed in counter parts and that electronic or fax signatures can be used in lieu of original wet signatures. d. Consultant will comply with all applicable federal state and local laws including the Health Insurance Portability and Accountability Act ("HIPAA"). IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: Daisy Gomez fi Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: c40'aa so„ tt• 2 Laura A. Rossini Senior Assistant City Attorney � EN�DED FOR PROVAL: Y/vI Steven PhAk Executive Director Human Resources Agency #5944v1 CITY OF SANTA ANA Kristine City Manager CONSU TANT: tam H. Nuesse, M,D. William H. Nuesse, M.D. and Mary Ann Nuesse, D.O., a medical corporation Dba Sunrise Multispecialist Medical Center EXHIBIT A RATES/CHARM 45944vl in William H. Nuesse, M.O. and Mary Ann Nuesse, D,O., a Medical Corporation dba Sunrise Multispeclallst Medical Center Exhibit A City of Santa Ana Non-tndustrial Medical Services Physicals: Basic Employer Physical (includes UA dip, distance vision, basic color vision) $35.00 Annual Employer Physical (includes UA dip, distance vision, basic color vision) $35.00 Pre -Employment Physical (includes UA dip, distance vision, basic color vision) $35.00 Fit For Duty/Return toWork (MUST hove copy otjob description) $40.00 Commercial Driver Exams $55,00 Resoiratory Fit Testing: Respiratory Eva]nation (includes: Mask Fit Test, OSHA questionnaire review, PFT) $90.00 PFT $40.00 OSHA Questionnaire Review $25.00 Mask fit Test $25.00 Drug Screens; Breath Alcohol Test $30.00 5 Panel Rapid $15.00 10 panel Rapid $20.00 9 Panel Non -Dot it1793N $25.00 10 Panel Non -Dot #6633N $30.00 DOT Drug Screen $25.00 MRO Interpretation of Positive Drug Screen $25.00 Drug Screen Collection only (Nat on Sunrise's lab account) $$5,00 V sion Testin ishihara $10.00 Near Vision $5.00 Jaeger $5.00 Snellen & Basic Color $5.00 Other Services: Audiograms $15,00 Lift Test— Floor to Waist $5.00 Lift Test— Waist to Chest $5.00 EKG $30.00 TB/PPD Skin Test $28.00 Chest X-Ray (2 Views rule out TB) $30,00 Lumbar X-Ray (4 Views) $50.00 Jamar Grip Strength $5.00 Vaccines• Tdap $95.00 Hepatitis 8 $70.00 Varicella $202.00 MMR $144.00 Flu Vaccine $30.00 Titers: Hepatitis A #35604 $45.00 Hepatitis 8 #8475 $45.00 Hepatitis C #8472 $21,00 MMR #802, #8624, and #964 $85.00 Varicella $45,00 gammon Labs: C8C with Diff #6399 $20.00 Lipid Panel #14852 $42.00 Camp Metabolic Panel #10231 $29.00 CERTIFICATE OF LIABILITY INSURANCE DATE /DD/YYYY) 0311313/2020 THIS CERTIFICATE IS ISSUED ASA 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 ACONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, ANDTHE CERTIFICATE HOLDER. IMPORTANT. Itthe certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions ofthe Policy, certain policies may require an endorsement. Astatementon this certificate does not confer rightstothe certificate holder In lieu afsuch endorsement(s). PRODUCER CONTACT NAME: Karen Noteboom Karen Noteboom(971557E) 18837 Brookhurst St Ste 201 PHONE (A/C, NO, EXT): 714-847-4488 FAX (A/C, NO): 714-965-6796 E-MAIL Fountain Valley CA 92708-7302 ADDIN:ss: knoteboom@farmersagent.com INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURERA: Truck Insurance Exchange 21709 SUNRISE MEDICAL CENTER INC. INSURERS: Farmers Insurance Exchange 21652 INSURERC: Mid Century Insurance Company 21687 867 S TUSTIN ST INSURER D: ORANGE CA 92856 INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMEABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADORE INSD SUBR WVD POLICY NUMBER POLICYEFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Y N 602378275 05/29/2019 / ✓ 05/29/2020 / ✓ EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED PREMISES (Ea Occurrence) $ 500,000 MEDEXP(Anyoneperson) $ 5,000 PERSONAL &ADV INJURY $ 2.000,000 GENT AGGREGATELIMITAPPLIES PER: X POLICY ❑ PROJECT ❑ LOC OTHER: GENERALAGGREGATE $ 4,000,00 PRODUCTS-COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANYAUTO OWNEDAUTOS SCHEDULED ONLY AUTOS HIREDAUTOS NON -OWNED ONLY AUTOSONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJ TRY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peraccident) $ UMBRELLALIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/ Y/N EXECUTIVEOFFICER/MEMBER EXCLUDED? (Mandatory in NH) ITyes, describe under DESCRIPTION OF OPERATIONS below N/A REVIEWED &APPROVED By Risk MarvaC1 EMEN win DIVISION PER STATUTE OTHER $ E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured on this policy pursuant to written contract, agreement, or memorandum of understanding. Such insurance as is afforded by this policy shall be primary, and any insurance carried by City shall be excess and noncontributory. CERTIFICATE HOLDER CANCELLATION CITY OF SANTTAITA SHOULD ANY OFTHEABOVE DESCRIBED POLICIES BE CANCELLED SEFORETHE EXPIRATION RISK MANAGEMENT DIVISION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 20 CIVIC CENTER PLAZA 4th FLOOR AUTHORIZED REPRESENTATIVE V ACORD25(2016/03) 31-1769 11-15 ©1988-2015 ACORD CORPORATION. All Rights Reserved The ACORD name and logo are registered marks of ACORD ACCMbir CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 1 li 03/05/2020 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 have ADDITIONAL INSURED provisions or 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 CONC NAME:TACarmen Ponce Calhoun &Associates PHONE IAI,No. E�u,g00-500-9799 aC N774.664-0614 DBA: Integrity Advisors n ORess: carmen@integrity-advisors.com 14771 Plaza Drive, Ste C INSURERS AFFORDING COVERAGE NAIC# Tustin CA 92780 INSURER,: EMPLOYERS 31283 INSURED William H. Nu/esse, M.D. and Mary -Ann Nuesse, D.O., A INSURER B : Medical ✓ INSURER C: 867 S TUSTIN ST. WsuRER D INSURER E ORANGE CA 92866 INSURER F COVERAGES CERTIFICATE NUMBER: RFVISInN NUMRFR- 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 ADDLSUSR POLICY NUMBER POLICY EFF MMIODIYYYY POLICY UP (MMODlYYY"I LIMBS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGETO-RENTED PREMISES Ea occurrence $ N ED UP (Any one person) $ PERSONAL &AOV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: POLICY JET LOG GENERALAGGREGATE $ PRODUCTS -COMPIOP AGG $ $ OTHER: AUTOMOBILE LIABILITYLi COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS accident Per 8001LV INJURY ( ) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accima t $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS-MADE DED RETENTIONS Z $ A WORKERS COMPENSATION or AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEWEXECUTIVE YIN (Mandatory inN REXCWDEDP Y❑ Ifyes,dgryin NH) NIA EIG267502901 08/01I2019 ✓ 08I01I2020 ✓ PER OTH- STATUTE ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1rDDOrODO DEescribe under SCRIPTION OF OPERATIONS be. E.L. DISEASE -POLICY LIMIT $ 1,000,000 00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) REVIEWED & APPROVED By Risk MANAGEMENT DIViSiON 8Uw 020 CERTIFICATE HOLDER CANCELLATION City of Santa Ana ✓ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Risk Management Division 20 Civic Center Plaza, 4th floor THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana, CA 92701 AUTHORIZEDREPRESENTATIVE 4 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Sunrise Advanced Work Injury & Urgent Care 867 South Tustin Street, Orange, California 92866 Tel:(714)771-1420 IFax: (714)771-6918 March 13, 2020 City of Santa Ana Risk Management Division ✓ 20 Civic Center Plaza, 4" floor Santa Ana, CA 92701 Re: Automobile Liability Insurance ✓ S6P ER The Medical Facility Agreement between the City of Santa Ana and Sunrise Multispecialist Medical Center is requesting that a certificate for Automobile Liability be provided. This letter will serve as notice that our vehicle status is different than listed in the agreement. Sunrise Multispecialist Medical Center does not offer any transportation services, nor do we have any owned, non -owned autos or other transportation services. All transportation services will be supplied by the City of Santa Ana. If you have any questions please contact us at 714-771-1420. Thank you, ✓ i ✓ ByRisk & MPP ENTpOV ON iam H. Nuesse, M.D. Medical Director AP 0 2 2 ANGIE ACEVEdO ENTITY CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Entity: William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Name ofDBAs: Sunrise Multispecialist Medical Center Inc MPT Entity: 1906 Effective Period: January 1, 2008 through December 31, 2020 Retroactive Date: February 1, 2000 The limit of liability of $1 million per Occurrence and $3 million aggregate will be *shared with the ✓ limits of MPT Members of the above named Entity. " A shared limit of liability for the Entity means that the Entity will share the limit of the MPT Members(s) whose acts, errors or omissions gave rise to the Occurrence. In the event that an Occurrence arises solely out of the acts, errors and omissions of a non-MPTHealthcare Practitioner who provides Professional Services for the Entity, the MPT Members of covered Entity shall share their limits of liability with the Entity. *' A separate limit of liability for the Entity means that the limits of the liability shall be in addition to and separate from (not shared with) the Ihnits of liability of the MPT Member(s) whose acts, errors or omissions gave rise to the Claim. In the event that an Occurrence arises solely out of the acts, errors and omissions of a non-MPT Healthcare Practitioner who provides Professional Services for the Entity, the MPT Members of covered Entity shall share their limits of liability with the Entity. Nothing in this Certificate of Coverage shall be construed to increase the limits of liability set forth in Part 1, Section 6.A of the MPTAgreement. The Mutual Protection Trust will provide the Claims defense and Claims payment services described in the MPT Agreement to the Entity named above, subject to all terms, conditions, and exclusions contained in the MPT Agreement, and subject to payment of any annual fees for Claims arising out of an Occurrence during the effective period set forth above. The coverage is continuous and uninterrupted unless cancelled or amended by MPT or the MPT Entity above. This certificate is incorporated by this reference and is a part of the MPT Agreement. This Entity's principals are responsible for notifying all recipients of this certificate should the Entity discontinue operation or dissolve before the end date shown above. Date: January 7, 2020 MUTUAL PROTECTION TRUST By Alfred De Leon Vice President, Membership Services REVIEWED & APPROVED By Risk MANAGEMENT DIVISION AP 0 g 1 y ANGiE ACEVEdo A e COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coverage through December31,2020 Member: Kenneth E. Grubbs, DO Address: 867 S Tustin Ave Orange, CA 92866 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection "rust (MPT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement. Membership Number 21463 Medical Specialty Family Medicine, With Minor Surgery Coverage Date February 1, 2012 Retroactive Coverage Date Nolte Subspecialty Coverage (Claims made and paid) Current Limits of Liability $1,000,000 for all Claims based ✓ Medical Professional LiabilityCoverage upon an Occurrence $3,000,000 each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage Claims History No Claims Reported The Claims history listed above includes all Claims that are currently open and those that were closed within the last five years. The Claims history does not include payments for emergency or other remedial expenses that may have been made to patients through MPT's Patient Assistance Services program. Cooperative of American Physicians, Inc. January 7, 2020 Alfred De Leon Date REVIEWED & APPROVED Vice President, Membership Services By Risk MApNA{�GEpMEgNTg1�nDIVISION Mutual Protection Trust ANGiE MEVEdO COOPERATIVE OP AMHRICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coveragethrough December31,2020 Member: Gerardo Canchola, MD Address: 867 S. Tustin Avenue Orange, CA 92866 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the teams, conditions and exclusions of the MPT Agreement. Membership Number 27237 Medical Specialty General Practice, With Minor Surgery Coverage Date September 12, 2016 Retroactive Coverage Date Norre Subspecialty !, Coverage (Claims made and paid) Current Limits of Liability $1,000,000 for all Claims based ✓ Medical Professional LiabilityCoverage upon an Occurrence $3,000,000 each calendar year ✓ aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage Claims History No Claims Reported The Claims history listed above includes all Claims that are currently open and those that were closed within the lastfive years. The Claims history does not include payments for emergency or other remedial expenses that may have been made to patients through MPT's Patient Assistance Services program Cooperative of American Physicians, Inc. January 7, 2020 Alfred De Leon Date Vice President, Membership Services REVIEWED & APPROVED Mutual Protection Trust By Risk MANAGEMENT DIVISION APR 8 2 ANC{iE ACEVEdO COOPERATIVE OF AMERICA.N PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2020 Member: William H. Nuesse, ME) Address- 867 S Tustin Ave Orange, CA 92866 This certificate confirms that, effective an the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement Membership Number 13924 Medical Specialty Family Medicine, With Minor Surgery Coverage Date April 1, 2004 Retroactive Coverage Date February 1, 2002 Subspecialty Coverage (Claims made and paid) Current Limits of Liability $1,000,000 for all Claims based ✓ Medical Professional Liability Coverage upon an Occurrence $3,000,000 each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage Cooperative of American Physicians, Inc. Alfred De Leon Vice President, Membership Services Mutual Protection Trust Date January 07, 2020 REVIEWED & APPROVED By Risk MANACEMENT DivisiON APA1 O 2020 OXCA AANVNgiinE`ACEVEdo y COOPERATIVE. OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coveragethrough December31,2020 Member: Mary -Ann Nuesse, DO Address: 867 S Tustin Ave Orange, CA 92866 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement Membership Number 13925 Medical Specialty Family Medicine, With Minor Surgery Coverage Date April 1, 2004 Retroactive Coverage Date February 1, 2002 Subspecialty Coverage (Claims made and paid) Current Limits of Liability $1,000,000 for all Claims based ✓ Medical Professional Liability Coverage upon an Occurrence $3,000,000 each calendar year / aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage Cooperative of American Physicians, Inc. Alfred De Leon Vice President, Membership Services Mutual Protection Trust Date January 07, 2020 RgE RIIEWM D & APPRANAqEMENTDIVISioOVED APf 8 22 20 ANGIE ACEVEdo EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Lindsay Ridding Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity. William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity #: 1906 Effective Date: February 29, 2016 through December 31, 2020 DBA(s): Sunrise Multispecialist Medical Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrencel$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference Into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage In the event of the termination of the employment of or other relationship with the above -named Worker. Such MemberlCovered Entity Is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage In the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST By r REVIEWFI) & APPROVED Alfred De Leon RR RISk MANAGEMENT DIVISION Vice President, MembersFix Services AAA 82020 „ p ANGIE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Emily Kahle Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity. William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity #: 1906 Effective Date: October 3, 2018 through December 31, 2020 DBA(s): Sunrise Multispecialist Medical Center Inc k" Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of ✓ liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named MemberfCovered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage In the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST �:;�-VIEWED & APPROVED By n., Dist. h4ANAgEMFNT DIVISION Alfred De Leon Vice President, Membership Setvicpc, 82 ZR o tt ANCfiE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) M Name of Worker: Dennis Wang Type of Worker Physician Assistant Employed by or related to the practice of the Member/Covered Entity: William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity #: 1906 Effective Date: June 22, 2018 through December 31, 2020 DBA(s): Sunrise Multispecialist Medical Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of ✓ liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage In the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST By � - REVIEWED & APPROVED Alfred De Leon y Risk MANAq&ENT DivisION Vice President, Membership Services APR B 20200 ANGIE ACEVEdD � �� �. �,: .. . :m .. EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: ArdeshirAlnassir / Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity: William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity* 1906 Effective Date: November 30, 2017 through December 31, 2020 DBA(s): Sunrise Multispecialist Medical Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and Ilcensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurret l83 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares hislher limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage In the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST IVA By E IEWED & APPROVED Il Alfred De Leon i DIVIsiON Vice President, Membership Se vip 2020 � nQ &YG _ ANGIE ,ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: John Diab ✓ Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity: William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity #: 1906 Effective Date: March 1, 2016 through December 31, 2020 DBA(s): Sunrise Multlspecialist Medical Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker Is based. This Certificate shall remain in force unless cancelled or amended by MPT or the MemberlCovered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST By R REVIEWED APPROVED Alfred De Leon B Risk MANAGEMENT DIVISION Vice President, Membership Suites APR,( 202 ANqIE ACEVE(IO ,r, EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker. Darrell Wilkins �/ Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity: William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity #: 1906 Effective Date: February 18, 2019 through December 31, 2020 ✓ DBA(s): Sunrise Multispecialist Medical Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrencel$3 Million Aggregate. Such limit of liability Is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the MemberlCovered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians. The above -named MemberlCovered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage In the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST By Alfred De Leon REVIEWED & APPROVED Vice President, MembershiWOWMANAGEMENT DIVISION — APR 0 g�2p� o ANGiE ACEVEdO �. r �< EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Amelia Kobravl Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity: William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity #: 1906 Effective Date: December 8, 2017 through December 31, 2020 DBA(s): Sunrise Multlspecialist Medical Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPTAgreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the MemberlCovered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity Is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage In the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST By PROVED Alfred De Leon Vice President, MembersQyQiSkftNAGEMENT DIVISION APR 0 $1 0„ �e ANGIE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Joshua Phillips Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity: William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity # 1906 Effective Date: October 14, 2019 through December 31, 2020 DBA(s): Sunrise Multlspecialist Medical Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPTAgreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker tar any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity, This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity Is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST By o[VIFWFI) R APPROVED Alfred De Leon RR I MANAGEMENT DIVISION Vice President, MembEP�h ervlces APR 20 ANgIE ACEVEdO 'F EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Amy Neterer / Type of Worker. Physician Assistant Employed by or related to the practice of the Member/Covered Entity: William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity #: 1906 / Effective Date: April 8, 2018 through December 31, 2020 DBA(s): Sunrise Multispecialist Medical Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPTAgreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of ✓ liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain In force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians. The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST By REVI€WEB & APPROVEC. Alfred De Leon R'tsl( MANAGEMENT DIVISION Vice President, Me ff$$TTiilp'Servlces AP 812Q0 p, ANGIE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Dan Tran Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity: William H Nuesse MD And Mary Ann Nuesse DO A Medical Corporation Membership # or Entity #: 1906 Effective Date: December 20, 2017 through December 31, 2020 DBA(s): Sunrise Multispecialist Medical Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a Contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage In the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity Is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Certificate of Professional Liability Coverage is modified. Date: January 7, 2020 MUTUAL PROTECTION TRUST By REVIEW[n x APPROVED Alfred De Leon [2` DEMENT DIVISION Vice President, Memhcl Sr fl�I S2t4t��g AP 822Q� � ANGIE ACEVEdO ACC) ® DATE(MM/DD/YYW) �►i CERTIFICATE OF LIABILITY INSURANCE 051OW020 THIS CERTIFICATE IS ISSUED AS AMATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AKIRMATIVELYOR NEGATIVELY AMEND, EXTEND ORALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OFINSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(5), AUTHORIZED REPRESENTATIVE OR PRODUCER, ANDTHE CERTIFICATE HOLDER. IMPORTANT: lithe certificate holder is an ADDITIONAL INSURED, the pies) nmstheve ADDITIONAL INSURED Provisions or be emorsed. ItSUBROGATION IS WAIVED, UIbiset to theterms and conditions of the policy, certain policies may "Ulm an endorsement. AstatemeMon M(sarHBea4dou not ConfarnBhtstotMeerUBeate hokkar in lieu of suchandorsement(s). PRODUCER Theresa Simes(9744576) 1716E Ne.Yhope St Ste F Fountain Valley CA 927D8.4230 INSURED _._.. WLLIAM H NUESSE M 867 S TUSTIN ST ORANGE CA 928M COVERAGES CUnFICATENUMBER: CONTACT NAME: Theresa Slmes PHONE FAX (A/C. NO. EXT): 714.966 W -3000 C.NO).'714.988-3013 EMAIL ADDRESS: tSlmes(Mtarmersagent oom INSURER(S) AFFORDING COVERAGE INSURERA Truck Insurance Exchange INSURERS: Famiers lnsurencelEX191al INSUREAC: M_M Century Insurance Company INSURER D: INSURERE: INSURER F. REVISION NUMBER: NAICa _r..__....IC# 21709 21652 21687 THIS IS TO CERTIFY TH0.T71,1E POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF MY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHX91 THIS CERTIFICATEMAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMNS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ITR TYPEOFINSUAANCE ISD WVD POUCYNUMSFR POLICY POUC/EX► (MM/DD/YYW) � (MM/DD/YYYY) LIMM COMMERCIALGENERALUABIUTY C WMS-MADE OCCUR ❑ / se I EACH OCCURRENCE S 2,000. DAMAGETORENTED PREMISES(EaOmxml $ SM.000 MEDEXP(A"Wepenen) S s5. PERSONAI.SADVINJURY S 2,0 A Y N 378275 OfL29/2020 o5129l2021 GENTAGGREGATEUMRMPUESPER: POLICY ❑ PROJECT 71 U LOC GENERALAGGREWTE S 4000 PRODUCTS-COMP/OPAGG f 2,DDD, AUTOMOBILE LMSILRY ANYAUTO / COMBINED SINGLE UMrT (Eaaoeident) S 2.000, BODILY INJURY (Per Perron) S `, O NEDAUT05 SCHEDUAUTOS LED 378278 OEd2972020 OW=021 BODILY INIURY(PwacNdnO) f _ PROPERTY DAMAGE (Per accident) S ��HIREDAUTOS x NON -OWNED ONLY AUTOS ONLY f UMBOR UAS OCCUR _-- EACHOCCURRENCE S AGGREGATE j EXCESS UAS CLAIMS -MADE DED RETENTIONS j AI "DEMPLOYERS-LIABRUTY C1 REVIEWED APP VED PER STAT UTE f ANY PROPRIETOR/PARTNER/ Y/N EXECUTIVE OFFICER/MEMBER N/A 1� y R(sK MANAGEMFNT iVISIUN E.L. EACH ACCIDENT S E.LOISEASE-EAEMPLOYEE EXCLUDED?(Mamlatoryln NN) "yes, describe under DESCRIPTION OF OPERATIONS below, 5 2()2 E.L DISEASE-PDLIDYLMIT S AFiEA7CEVEdD DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (/ICBRD 101. Additional Remarks Schedule, may be attached Itmere spa; is Required) 7 S TUSTIN ST, ORANGE, CA 92866 Certificate of Insurance shall provide thirty(30) day prior written notice of cancellation CERIIFIGTEHOLDER CANCELLATION CITY OF SANTA ANA ISK MANAGEMENT DIVISIC SHOULDANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 20 CIVIC CENTER PLZ J/ DATE THEREOF. NOTICE WILL BE DENUANCE IN THE POLICY PROVISIONS. AYlH01@ED REPR[SENTpTIVE i SANTA MIA CA-92701-� ... ACORD 25 (2016/03) 01988-201S ACORD CORPORATION. All Rights Reserved 3I- I769 11.15 The ACORD name and logo are registered marks of ACORD r_ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY NUMBER: 602378275 FARMERS INSURANCE ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM BUSINESSOWNERS COVERAGE FORM APARTMENTOWNERS LIABILITY COVERAGE FORM CONDOMINIUM LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Persons) Or Organization(s): jC1TY-GF S CtTTXWNA1:UWMARAGEMENT jNf5M— Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. The following is added to Paragraph C. Who Is An Insured of the applicable Coverage Form: j7238 1st Edition Any person(s) or organization(s) shown in the Schedule is also an additional insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf in the performance of your ongoing operations or in connection with your premises owned by or rented to you. However: a. The insurance afforded to such additional insured only applies to the extent permitted bylaw; and b. If coverage provided to the additional insured is required by a contractor agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Paragraph D. Liability And Medical Expenses Limits Of Insurance of the applicable Coverage Form: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable Limits Of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits Of Insurance shown in the Declarations. REVIEWED & APPROVED By Risk MANAGEMENT DIVISION M 2020 ANGIE ACEVEdO This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all the terms of the policy. J7238-ED102-19 Includes copyrighted material of insurance Services Office, Inc., with its permission. Pagel oft 937238 J7238101 NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor William H. Nuesse, M.D. and Mary-Ann Nuesse, D.O. Name: Project N-2021-179-01 Number: Project First Amendment To Agreement For Medical Services And Testing Name: The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: POLICY EXPIRATION TYPE OF INSURANCE COI DATE FILE NAME NUMBER DATE Sunrise COI Exp AUTOMOBILE LIABILITY 602378275 05/29/2023 01/11/2023 05-29-23.pdf Sunrise COI Exp GENERAL LIABILITY 602378275 05/29/2023 05/13/2022 05-29-23.pdf 2023 CAP MPT - Doctors - PROFESSIONAL LIABILITY COC 12/31/2023 01/10/2023 Certificate of Coverage.pdf City of Santa WORKERS COMPENSATION AND 25601701 08/01/2023 10/03/2022 Ana, Risk EMPLOYERS' LIABILITY Management.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 1/11/2023 5:55 PM