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HomeMy WebLinkAboutWILLIAM H. NUESSE M.D. AND MARY ANN NUESSE, D.O. dba SUNRISE MULTISPECIALIST MEDICAL CENTERINSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES 5 •2F� • ZoZ S CLERK OF COUNCIL DATE: AUG 18 2022 AGREEMENT FOR MEDICAL SERVICES AND TESTING A-2022-152 THIS AGREEMENT is made and entered into this 7th day of June, 2022 by and between William H. Nuesse, M.D. and Mary Ann Nuesse, D.O., a California medical corporation, doing business as Sunrise Multispecialist Medical Center ("Consultant"), and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). RECITALS A. City desires to retain a consultant to provide non -industrial medical services including but not limited to Department of Transportation ("DOT") mandated services, drug tests, respiratory fitness tests, vision testing, post -accident testing, pre -employment examinations, fitness for duty examinations, COVID-19 testing and similar medical services for employees or applicants for employment. B. In undertaking the performance of this Agreement, Consultant represents that it employs a licensed medical doctor and 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 licensed professional. 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: 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") mandated services, COVID-19 testing, 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: 1) 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 CPR, Part 40; such testing to include pre -employment and pre - assignment; and 7) COVID-19 testing. 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 "posf-accident" drug and alcohol testing, Consultant shall facilitate evaluation of the 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 Services 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. D. As part of the medical services review program, Consultant shall: 1) 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. 8) 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. 10) Consultant solely shall review all pre-employment/pre-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 permitted by law. 1 1) 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 without written permission, unless such disclosure is required by law. Consultant shall not be required to create or maintain books and records not 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 IegaUmedical/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. G. 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 of near/far/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; C$C w/diff; dipstick UA, or UA w/Micro (to lab); venipuncture & collection. 2. 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 two hundred thousand dollars and zero cents ($200,000) during the term of this Agreement. b. 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, 2025, 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 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. INSURANCE Coverage shall be at least as broad as: I. Commercial General Liability (CGL); Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis, including products and completed operations, property damage, bodily injury and personal & advertising injury with limits no less than $2,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this project/location (ISO CG 25 03 or 25 04) or the generalaggregate limit shall be twice the required occurrence limit. 2. Automobile Liability: Insurance Services Office Form Number CA 0001 covering, Code (any auto), or if Consultant has no owned autos, Code 8 (hired) and 9 (non -owned), withlimit no less than $1,000,000 per accident for bodily injury and property damage. (Not required if Consultant has no automobiles) 3, Workers' Compensation insurance as required by the State of California, with Statutory Limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. 4. Professional Liability (Errors and Omissions) Insurance appropriates to the Consultant'sprofession, with limit no less than $2,000,000 per occurrence or claim, $2,000,000aggregate. If the Consultant maintains broader coverage and/or higher limits than the minimums shown above, the City requires and shall be entitled to the broader coverage and/or the higher limits maintained by the Consultant. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the City. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following provisions: Additional Insured Status The City, its officers, officials, employees, and volunteers are to be covered as additional insureds on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Consultant including materials, parts, or equipment furnished in connection with such work or operations. General liability coverage can be provided in the form of an endorsement to the Consultant's insurance (at least as broad as ISO Form CG 20 10 11 85 or both CG 20 10, CG 20 26, CG 20 33, or CG 20 38; r� CG 20 37 forms if later revisions used). 6. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from 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 relates to the services described in section 1 of this Agreement; and (2) from 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 events referred to in this Section or by reason of the terms of, or effects, arising from 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 terms 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. 7. 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 longer period required by law, from the date of final 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 make 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 from the date of final payment to Consultant under this Agreement. 8. CONFIDENTIALPPY 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 disclose such information 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 in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information 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 (e) is independently developed by the Consultant without reference 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, 11. BACKGROUND CHECK REQUIREMENTS Consultant shall not 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 seg, has a conviction for any 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 Code Section 1192.7(c). 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 shall 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. Box 1988 Santa Ana, CA 92702-1988 Fax 714-647-6956 With Courtesy Copy to: Executive Director Human Resources Agency City of Santa Ana 20 Civic Center Plaza (M-34) P.O. Box 1988 Santa Ana, California 92702 To Consultant: William H. Nuesse, M.D. or Mary Ann Nuesse, D.O. Sunrise Multispecialist Medical Center 867 South Tustin Street Orange, California 92866 Fax:714-771-6918 A party may change its address by giving notice in 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, EXCLUSIVITY 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 parties 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 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 set -vices 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. NONDISCRIMINATION 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, and 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 term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the 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 permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 19. MISCELLANEOUS PROVISIONS A. Each undersigned represents and warrants that its signature herein below has the 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 attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. b. 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"). [This section intentionally left blank] IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: i aisy Gomez ,Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: Jf a..ne Laura A. Rossini Chief Assistant City Attorney RECOMMENDED FOR APPROVAL: Motsick tive Director n Resources Agency CITY OF SANTA ANA Kristine Ridge City Manager William H. Nuesse, M.D. William H. Nuesse, M.D. and Mary Ann Nuesse, D.O., a medical corporation Dba Sunrise Multispecialist Medical Center 10 ExHIB[T A RATES/CHARGES 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 to Work (MUST have copy ol'job description) $40,00 Commercial Driver Exams $55.00 Respiratory Fit Testing: Respiratory Evaluation (includes: Mask Fit Test, OSHA questionnaire review, PFT) $90.00 PFT $40.00 OSHA Questionnaire Review $25.00 Mask Fit Test $25.00 DM Screens: Breath Alcohol Test $30.00 5 Panel Rapid $15.00 10 panel Rapid $20.00 9 Panel Non -Dot 111793N $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 (Not on Sunrise's lab account) $15.00 Vision Testing: Ishihara Near Vision Jaeger Snellen & Basic Color Other Services: Audiograms Li ft Test — Floor to Waist Lift Test— Waist to Chest EKG 'I'B/PPD Skin Test Chest X-Ray (2 Views rule out TB) Lumbar X-Ray (4 Views) Jamar Grip Strength Vaccines: Tdap Hepatitis B Varicella MMR Flu Vaccine Titers: Hepatitis A #35604 Hepatitis B #8475 $10.00 $5,00 $5.00 $5.00 $15.00 $5.00 $5.00 $30.00 $28.00 $30.00 $50.00 $5.00 $95.00 $70.00 $202.00 $144.00 $30.00 $45.00 $45.00 12 Hepatitis C #8472 $21.00 MMR #802, #8624, and #964 $85.00 Varicel la $45.00 Comi0on Labs: CBC with Diff #6399 $20,00 Lipid Panel #14852 $42.00 Comp Metabolic Panel #10231 $29.00 COVID-19: Rapid AntigenTesting $99.00 PCR $150.00 13 ME COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2022 Member: Kenneth E. Grubbs, DO Address: 867 S Tustin Ave Orange, CA 92866 Samantha °g1°"Sgne°hy an"M.lamMi M. Lambert 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 12803. 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 None 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 Penod. 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 November 11, 2021 a� Rhlrhluvg�erltDtrl:ai "„ Rta[weo6MVRovm Bv: $.t.ntsit�s Ietn.r'-- ' Ruk Management Smpl,v, o COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2022 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 (MPTy MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section I2807. 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 Date Vice President, Membership Services Mutual Protection Trust November 11, 2021 ed'° "r R E SMvaovmBr -9401W Risk Management Supervi,ei LVE COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2022 Member: William H. Nuesse, MO 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 12807. 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 $3,000,000 each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any parry, other than the named member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust November 11, 2021 .� • WiManaglmekD RBy. tn�Eavan6A�ra aov®Br. Rbk Mana�ern,r Suprviscr ACRH Samantha Samantsigned ha M. abY CERTIFICATE OF LIABILITY INSt�405zo�ooz °"05/732022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITLMEACONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, 00 THE CERTIFICATE HOLDER, IMPORTANT If the cerORcats holder Is an ADDITIONAL INSURED, the pulh:y(Les) mud have ADDITIONAL INSURED provisions of he endorsed. IfSUBROGATION IS WAIVED, sub)ectto theta;- and conditions of the Policy, certain policies may require an endorsement Astatementon this certificate does mtoefer rightatothecenthateh0derin Beu otauchemlorsement(s). PRODUCER CONTACT NAME: Theresa Simes Theresa Simes(9744576) 17165 Newhope St Ste F PHONE WC, NO, EXD: 714-966-3000 FAX to/C. ND): 714-966-3013 E-MAIL Fountain Valley CA 927084230 ADDRESS: taiMGS@farmemagent.com 1%SURER(5)APFORtnNGCOVERAGE NAIC# INSURED INSURERA; Truck Insurance EXChange 21709 iN$umaw. Farmers Insurance Exchange 2165 2 WYLM H S . TUSTIN ST M.D. 67 867 S N INSURER C: Mid Century Insurance Company 21687 - INSURERU ORANGE CA 92866 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THISISTOCERMFOHATTHEPOUC1E50FINSURANCE USTED 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 INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN RMUCEDBY PAID CLAIMS. I= LTR TYPEOFINSURANCE ADOTL WSO SUBR WVD POLICY NUMBER POLICYEFF (MM1L11C YYJ POLICY BIG, (MM/OD/YYYY) LIMITS A COMMERCIALGENERALUABILRY CLAIMS -MADE OCCUR. Y N 602378275 05/29/2022 05/29/2023 EACH OCCURRENCE S 2,000,00 DAMAGE TO RENTED PREMISES(F. Occurrence) $ 1,000,00 MEDEXP(Anyoneperson) $ 1000 PERSONAL&ADVINJURY $ 2,OW,000 GENT AGGREGATE LIMIT APPLIES PER; POLICY ❑ PROJECT ❑ LOC OTHER: GENERALAGGREGATE Q 0000 PRODUCTS-COMP/OPAGG S 2,000, $ A ALITOMOBILELIABIUTY ANYAUTO ONNEDAUT05 SCHEDULED HIREDAUTOS X NON -OWNED ONLY AUTOSONLY N r2378275 05129J2022 D5129)2023 COMBINED SINGLE LIMIT Me accident) S 2,000,00 BODILY INJURY (Per person) S BODILY INJURY(P"Uddent) S PROPERTY DAMAGE (Peraccident) $ S LIUMBRELLAUAB ri EXLU: UAB OCCUR CLMMSMADE EACHOCCURRENCE $ AGGREGATE $ OEO RETENTION$ § WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARCNERJ Y/N EXECUTIVE OFFICER/MEMBER EXCLUDEDT(Mandaturym NH) I Ryas, describe under DESCRIPTION OF OPERATIONS below N/A PER STATUTE OTHER S E.L EACH ACCIDENT $ E.L. OISEASE,EA EMPLOYEE E.L. DISEASE -POLICY LIMIT $ 1 T-7 DESCRIPTION OF OPERATIONS LOCATIONS/VEHICLES(ACORD 101, Additlanafks al RemSchedule, may be attached lfinore space is required) 867 S TUSTIN ST, ORAN�E, CA 92866 WdtMwbangdl)bidglL �/ REVIEWED&APPRCVEO6Y: IWO 4 Risk A9anagementSuperv¢O, CERTIFICATE HOLDER CANCELLATION CITY OFSANTAANARISK MANAGEMENTOIVIISK 20 CIVIC CENTER PLZ SHGI"ANYOFTHEABOVEDESCRIB POUCI DATE THEREOF NOTKE WILL BE " EO AUTHORIZEDREPRESENT da(� lXl i ACOR132S(2016/03) 17-176q 11-15 ®1988-2015 ACORD CORPORATION. All Rights Reserved The ACORD name and Ingo are registered marks of ACORD 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 to will be shown in A. The following is added to Paragraph C. Who lsAnInsured ofthe applicable Coverage Form: j7238 1 at 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 contractor agreement to provide forsuch 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. This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is oth terms of the policy. RukMwgnwdiRsidan 4. y+� REVIEWED&APPRDv®BY: w ® Risk Management Supervisor J7238-ED 1 02-19 Includes Copyrighted material of Insurance office, Inc., with its permission. 937238 Page 1 of 1 17238101 NOTICE OF COMPLIANCE CITY "A,AM I1111RINT I'IIII Pi I1111A E AND INCLUDE Ck I 111 1AGREEMENTTOT111IE CLERK CSC 1111IE 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: TYPE OF INSURANCE POLICY EXPIRATION COI DATE FILE NAME NUMBER DATE AUTOMOBILE LIABILITY 602378275 05/29/2023 01/11/2023 Sunrise COI Exp 05-29-23.pdf GENERAL LIABILITY 602378275 05/29/2023 05/13/2022 Sunrise COI Exp 05-29-23.pdf 2023 CAP MPT PROFESSIONAL LIABILITY COC 12/31/2023 01/10/2023 - Doctors - Certificate of Coverage.pdf WORKERS COMPENSATION AND City of Santa EMPLOYERS' LIABILITY 25601701 08/01/2023 10/03/2022 Ana, Risk Management.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 1/11/2023 5:55 PM In NOTICE OF COMPLIANCE CITY "A,AM I1111RI TI'Ill IllPi III1.IC E AND INCLUDE Ck IT111 1 .1GR➢C➢C kt➢CNT O 111I➢C CLERK t" T11111IE COUNCIL Contractor William H. Nuesse, M.D. and Mary -Ann Nuesse, D.O. Name: Project N-2021-179 Number: Project 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: TYPE OF INSURANCE POLICY EXPIRATION COI DATE FILE NAME NUMBER DATE 2023.05.15 AUTOMOBILE LIABILITY 602378275 05/29/2024 05/15/2023 sunrise col 1 Al city of SA.pdf 2023.05.17 GENERAL LIABILITY 602378275 05/29/2024 05/17/2023 sunrise col 1 Al City of SA updated.pdf 2023 CAP MPT - PROFESSIONAL LIABILITY COC 12/31/2023 01/10/2023 Doctors - Certificate of Coverage.pdf WORKERS COMPENSATION AND 25601701 08/01/2024 07/17/2023 City of Santa EMPLOYERS' LIABILITY Ana.pdf Thank you, ___� ACC>R "a CERTIFICATE OF 10117120 LIABILITY INSURANCE DATE /YYYY) 17l2024 THIS CERTI FICATE IS ISSUED AS A MATTER OFINFORMATION ONLY AND CONFERS O RIGHTS UPON THE CERUFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA"fIVEI.Y AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TI IIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), j AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. FIMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) mu oa have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the Policy, certain policies may requi re an endorsement. A statement n this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Theresa Simes Theresa Simes(9744876) 17165 Newhope St Ste F Fount a! vg i-e 927 42 AN 1. ..eve INSURED William H Nuesse M.D. and Mary Anne Nuesse D.O. A Medical Corporation DBA: Sunrise Multispecialist Medical Center 8637 S. TUSTIN ST. ORANGE CA 92866 COVERAGES CERTIFICATE NUMBER: Ti iIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IS_ REOUIREMENT. TERM OR CONDITION OF ANY CONTRACTOR OTHFR DOCUMENT WI1 POUCIES DESCRIBED i rERLIN IS SUBJECT 1-0 ALL i HE I+RMS. EXCLUSIONS AND CON . INSR ADDTL SUOR Ll R TYPE OF INSURANCE INSD WVD COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR A Y N 602378 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY n PROJECT n LOC �J LJ OTHER - AUTOMOBILE LIABILITY ANY AUTO F A I OWNEDALITOS I SCHEDULED I r I ONLY I AUTOS N ,602378 HIREDAUTOS �X NON -OWNED ON LY AUTOS ONLY UMBRELLA LIAR OCCUR B EXCESS LIAB CIAIMS-I AADE I fED RUI t=N I ION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PAR'I NER/ WN EXECUi IVE OFFICER/MEMBER EXCLUDED? Wandatory in NH) If ties, describe under DESCRIPTION OF OPERATIONS below N/A PHONE FAX (A/C, NO, EXT): 714-966-3000 (A/C, NO): 714-966-3013 E ILL A : i to rnedab Anaie Ac_ev_ec� ftsr INSURERS AFFORDING COVERAGE 'AIC P I e u JeQxclatgelT 6:07:55 -07I 00709 INSURER B: Farmers Insurance Exchange 21652 INSURERC: Mid Century Insurance Company 21687 INSURER D: INSURER E: INSURER F: REVISION NUMBER: UEDTOTHE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY H RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAir4. THE INSURANCEAFFORDED BY THE -ITIONS OF SUCH POLICIES. LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -OLICY NUMBER POLICY EFF POLICY EXP T LIMITS (MM/DD/YYYY) I (MM/DD/YYYY) 5 ?75 71781I}81 I DESCRIPTION OF OP :RATIONS/LOCATIONS/ VEHICLES (ACORD 101, Additional Rer P67 S TUSTIN ST, ORANGE, CA 92866 jCertificate of insurance shall provide 30days prior written notice of can CERTIFICATE HOLDER CITY OF SANTA ANA 20 CIVIC CENTER PL? SANTA ANA ACORD 25 (2016/03) 31-1769 1 1.15 CA 92701 The ACORD name EACH OCCURRENCE —I$ 2.000.000 DAMAGE TO RENTED f PREMISES (Ea Occvrrence) $ 1,000.000 M E D EX (Arty ory person) 'S 10000 05/29/2025 ! PERSONAL &ADV INIUK'y dS 2.000,000 I GkN£RAL AGGREGATE 4,000,000 PRODUCTS -COMP/OPAGG 'S 2,000.000 g COMBINED SINGLE LIMIT (Ea accident) 2,000,000 BODILY INJURY (Per person) �5 I 05/29/2025 BODILY INJURY (Per accident)'S PROPERTY DAMAGE (Per accident) IS EACH OCCURRENCE h5 1,000.000 - I 05/29/2025 1 AGGREGATE S 1,000.00 3 PER STATUTE OTHER S E.L. rACH ACCIDENT S E L. DISEASE- EA I:MPI.OYEE b E.L. DISEASE - POLICY LIMIT F rks Schedule, may he attached if more space is required) I:ellation CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES I: DATE THEREOF. NOTICE WILL BE DELIVERED IN ACC DMsion AUTHORIZED REPRESENTATIVE EEED PRCFVEDBy . �I �. Risk Management Specialist n 1988-2015 ACORD i nd logo are registered marks of ACORD THIS ENDORSEMENT CH)WSES TH E VOL ICY. PLEASE READ IT CAR EFU LLY. IN, j71 00 F A R M E Ft 2.nd Editl Q T) INSURANCE PRIMARY AND NONCONTRIBUTORY INSURANCE Ihisendorsement nnodiffes inswan-ceprovidedunone: GUSINESSOWN ERS POLICY SCNEDULE I Name of Additional Insured Person.5(s) or Organ zation(s): .1 . . ............. - .............. ................. CITY OF SANT A MA. Of FICERS. ric I -SEEJ71 OSAMENOTOADDNL INS ...... .......... Unforniation required to complete this Schedule, if s[iown above, will be showil I n the Declarat.iom.. The following Is added to Parac ir-aph H. Other InSUIrance Qf thQ Bus inessowners Common Policy Conditions and SUPersedes all' pf ovis 1 u r i to t h e cc- ii t ra ry: Primavy arid Noncontributory Insurance llils insurance is prirridry to and wl 11 riot seek co . it i bution ftom airy other i iiw aiice- avail ab[c Lo the adds timial insured shoo vii lil the SChe&111�, provided that.- 1 . flie ads Wonal MW.red shown in the Schedule is a Natned Insured under -such other fristif x ice; 2You havc- agreed in writing In a contract or agrlp.eio-iic that this instirancq, vvc)t4j(.j be p(-trilary aric-1 viould riot seek r-onitt iWition from any other Insurance avallable to tho addi buynal inSLjred+ and 3. The addl tional Insured shown In this Schedd le Is also a ii Additional Insured on ui is pup icy. The coverage Provided udder thlri endorserii fU Is sul>ject to the terms and condItions of th.a applicable, i.jnderlyins; Additional insured 011dorsemen L. I This endorse in en t is part of your po 1Icy. It SUpersede a n d controls a nyt h i rig to t h e con t r ary. It is otherwise s u bj ec I to a I I t 1-1 e I t5 r ri 1-� of the policy -ite ial of Insurance Services Uff ice, hit, �Ni H i I is per rnfi�s 17100- E D2 0 5-18 111 cl ud es col.-qr iq I LeLf n i L mok Mmsgma& Division 9 a-7 I Q 0 M, . REVIEWED & APPRoveD By. A( zvd-a Risk Management Specialist POLICY NtJMBER: 6023 7 - 82- 75 THIS E N DORSE ME NT CH AN FARMER� INSURANCE AMENDMEN', Tip is endorsemerit modifies Insurarice pr nvided undt- BUSJNBSOWNU6COVEJ�AGEFORM LIABILITY COVFRAGE F-01R'W BU IL 01 N G AW P ERS ONA L P ROP E R'TY COVERA CWOMERCIAL GE N ERAL L I LITY COVERAGE- I APART'MEN'l OWNLRS LIABILI'I'Y COVERAGE FQ (,QN DGMINIUM LIABILITY COVE$1AGE FORM Name(.$) Of Additional Insured Person(s) or org CITY OF SAN �rA ANAo 0 F F I CEr x AGE N TSo EMPLOYEES, AND VO [- U N-FE E RS ARE NAME D AS ADD I T1 ONALLY INSURED ON THIS POLICY 7 1 os-F-in 05- 1 a 93-7105 I ncludes cv py r laht &d ma 6ESTHE POLICY. PLEASE READ ITCAREFULLY. j710-5 3rd Edition w OF ADDITIONAL I NSU RED r the. iE FORM ORM � rm SCHEDULE nization(s); er ia I of I ns i. ra n ce Sets keS Of f 1'ce, I n-t, with its pt-rj�-% h�s i on. Risk Mmsgana& DMslon 113; 1 - REVIEWED & APPRc)veD By. A� A( zvd-a Risk Management Specialist v- Policy ( anges Endorsement Dow"I'plion ADD Aid D17'TOVAL INTEREST A 0 1) 1 TI ONNA L I NSURL'. D -171 ()()�F D 2 CITY 0-1- SANTA ANA. OFFICERS. Ada r-.N i�, F M PL M-'- F, S. AN 1) 10 C"'v I C, C PNTER P 1, Z SANTA ANA, CA 9-91#71) 1 LO(ATIO.N.- 867STUSTINiST OrvkN G E. CA WS 6 fi R-CITIOV;d It' C.'OV(-J-L-d 11nipci-ty is winovcd to a 1jew 1OC311011 thAL is dLSC1-1bvd oll 1111s Nflicy Permit ("hange, vull May extend Mi.,, insurance io indlidt. flut Cover-C-d Prolwrlv nl knch juring �11C rrflwv�11. ('10Wrage al k7ach Irocm)(m WL11- ;AP151V ill (11v P-01101'tioll (hat lbe walu.-C at iruch 1(W4-ilitln bew-S to [lie V-41111c ILIC Al CvV 4L)%"(Nl 11 iis I)CITRI it at � P1 vs 11 P to 10 day $ af I C r I I w ef I i VC. -L 14-1 tv f') C t I I Is P Chw zp-; afor that, thiS iffilIT-IJ WC &CS 11 at i I V1 i1j)[4y e hv prcyiows 714271 1ST 7-N E42774DI Indulm CWY! iglol "ri:rend, lzurop. ionim Ofhtt, ln. -.ki D5 V I nor atj- Risk Mmsgma& DMslun REVIEWED & APPRc)veD By. Risk Management Specialist The persuri oi orgaTiization listed above is added Lo lie ........ . ......... Additional InSUred - Controlling Interest Add i L i o n al In.5u red - Co -Own e r of Insure rem I ses Additional Insured - Designated Person 0 0 r 9 a n iza tion Addi tional Insured - Enqlneers, Arch i tee Ls Or Skirveyot s Not Engaged By Tile NaTlIed I(ISUred Additi011al 11`1:hUt-ed - Grantor Of Franchise Additional Insured - Lessor of Leased Equ;:pi nel It Additional Insured - Managers or Lesserzif Fir- ern I 51C3 L-) - --.- ............ .... .. Add f tl on a I I n su ved - M or t gagee, Assi y i i eq u r R e cei ve r Add i U on a I In s u red - 0 wn ers, Lessees Or n tr actors Additional Insured - Owners or Other Interests froni Whorn Land f las Been Leased Additional Insured - Pr i mar y and Noncon.r i Nj Lwy Additional hisuTed - Scheduled Peison 01' orgallizatiall Additional lriskired - State or Political Subk-fivision5 Permits Additional Insured - State or Poli fic2l S� lbrAlvisions Parmits Relati ng to P r�Fnises Addl tion al Insured - Vendors river of Ri g h ts Re covery . ............................ Other ThIs endortiement is part of your policy. Itsuperse es arid con triols anyft nq to the contrary. It is otherwise subject to all th#� Let ills Ur U le policy. J7105-ED3 05-18 1 ind udes copy, rig hit ed mo t of I nsurance S-ery ices Of f ke, I ric., with its pe rmiss iop i, - -Q-" Risk Mmsganeni DMslon REmEWED & APPRoveD By: Risk Management Specialist TH IS ENDORSEMENT CHANGESTH E POLICY, PLEASE READ IT CAREFULLY. 1) NU MB ER: 6 02 3 7 82 7 5 j7238 AtS1r,% Istridition --,wr en FARMERS IN 5 Uhl ja 14C E ADDITIONAL INSURED - DMIGNATED PERSON OR ORGANIZATION This end orsernen t nio d iti es insurance pvoy ided undue . the foIto,win g 6 U51N E55014 �N UR 5 LIAblUl Y COVE RAGE FORM SUSIN ESSOWN EkS COVERAGE FORM A-PARTM ENTOWNER$ LIABILITY COVERAGE FOf CONDOMINIUM LIABILITY COVF.RAGE FORM r Ir 'at N a nke Of Ad di Vona I I im suired Pe rson(s) 0 r 0 rga n I I C I TY OF SAN TA ANA: R1 SK MANAGEMENT D IM S] Of4 I nrormation required to comp] L-te ttlis Schedule, it 11 t shown above, will be sho-vin In thpL A. Thy following is addi.-A to Paragraph C. Who of J,n Insured of the �pplicaLk, Coverage Form. Any persori(s) or orgariizattoij(s) stjovvn if the SChedule is also an additional insured. but only with -rc-!spcct to liability for "'bodily injury", "preiper-ty damage" or j�,efs* tw I and adverti5i n g injury"' c a w sed, in who I e or I t I f�,j �-t. by or QMjSS OF4� .!� our acts o r o av SS 10 rl-z a r the L mg on your behalf In the performaince of your ongoing operations or in conne-ctiari with your prem ses ovals d by or ren t k2id Lo you, Howavlw- a. The inWrance afforded to such oddity al insured only appljLt.s to th;-% extent permiltc-,d by law; anc.] b, If coverage, provided to the additional -insured isrequired by el v.-mrActaragrcaement, tfti insurance 4fofrled t13 q such additional insured will not be br-a ader than that whic'h ytw �:ra 1 equire-d by the contrail vr- ag r-ferrnunt to provide for such additional Insured. B. Vilith respect to tlw inwranee atforded to theS additional Insureds, the tallowitig N; added to Paragraph D. LiabilitV And M a d teal Expens s Liml ta Of If I s ura nce of the a p p 11 c abtv Cover -aye Fir ; If c ove rag �& p rov Opel to the ri cid i ri onal 4 r1su rp- d i!; recl U i roll by a contra & rjr a g irepm on t, the most w� w i I I j�a y ors i)c-n r-, I t of the additional in-sureist11-F}r-tm0Vnt0t1nSLjraac 1. Required by the contract or 8greomio&.nt; or 2. Awsilable under the We- Liniit!s Of 1�1;5 irt,5f,;,vshown ui (tie L)�claraviorI5; whichever is iess. This endorsement shah not incri�as* t he applica in the M7,,clarationq- This endorsement is part of your policy, [t!sjjper!sed and controls a nything to the contrary, It is otherwi �,e su0jlect to all the terms of the. po I icy. t J7236-ED1 02-.19 1 llcludt� �Q.Pyri Q 1-ijed wwtc riaj L;f I r a2, u rdnce 5trwisu:P Orrick?, tnc., m lb i ts pur mrw,s a i R1&Mmsgana&DMsibrL RE\AEWED & APPRoveD By. Risk Management Specialist I NJ MS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Irk**% FARM E R a E3306 INSURANCE I st Edition WAIVER OF TR INSFER OF RIGHTS OF RECOVERY AG A G INSTOTHERSTOUS 05i2-0i2024,1 Effective -bat -e- "--- ��'o This endorsernent modifies instirance providEci �nder the fullowirig: B USI N ESSOWNERS COMM 0 N POLICY CC N D I T1 ONS - 6 P 00 09 SCHEDULE Name of Person or Organization: CITY OF SANTA ANA RISK �AANAGE M EINT D 11 SJO N It no entry appears above, information reclLdre to compm lete this Endorsement ust be-showniin the Declariatioiis as nm applicable to this edorseent.) 11 Tj-lie provislo ris of the BLI'SifleSSOW11el'S Com Imo n Po I icy Co ndi boos. a re mod if ic-d by th is enda rsernent as follows: r ahis Co i -�d I t io ii K. Tyra nsfe r 0 f Rig h is Of Recove:ry t Others To Us in the Bu-si nessowners Corte tnon P licy Coi id III o ns is amend by the add Itila n of the fo171cowi ng-. 3. We waive any right of recovery we. may have agairiot the person o r oi'q a nization shown i n the Schedd le above because of payments we make (a r inil.] ry or da niage a rising ising out of your ark done under a contr ctwith that person or organization a nd incl ud ed In the P rod u cts- ca rn P] et e d o pe ra t io n s hard. T h -s Y-v a ive r ap plies o ri ly to the- person o r orgy nizatio n s. own in the Sr- hed u le a 13 ove. This endonsement Is 13aft of your policy. It Super eider and cmitrols, anything to the cap M-ary, It Is 4c.) t I i P�-uv I s i j d I I t he to r1l 15 Of the PU 6 L Y. f E3306-EDI 6-97 1 f i r, 1. u d us Cc py rig hLed Mats i a I v F I risv ra nct-- Servi Ce S 0 f fice, I I I.C., Vf i tf 0 ESN Per TFIi!i 0 1, 1. Ri&MmsganeniDMs1on REVIEWED & APPRovED By. Xi Risk Management Specialist NJ ACOR" DATE MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE7051/28/2025 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 i 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 CONTACT NAME: Theresa Simes Theresa Simes(9744876) PHONE FAX 17165 Newhope St Ste F (A/C.NO,EXT): 714-966-3000 (A/C.NO):714-966-3013 E-MAIL - Fountain Valley CA 92708-4230 aooREss: tsimesQ(armersagent.com i INSURER(S)AFFORDING COVERAGE NAIC x INSURED INSURERA: Truck Insurance Exchange 21709 William H Nuesse M.D. and Mary Anne Nuesse D.O INSURER B: Fanners Insurance Exchange 21652 A Medical Corporation. INSURERC. Mid Century Insurance Company 21687 INSURER D: dba:Sunrise Multispecialist Medical Center 867 S TUSTIN ST.ORANGE CA 92866 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ['HIS 15 TO CERTIFY THATTHE 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 CONTRACT OROTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDTL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 2,OW,00 CIAIMSMADF OCCUR DAMAGETORENTED S PREMISES(Ea Occurrence) 1,000.00 MED EXP(Any one person) S 10.000 A Y Y 602378275 05/29/2025 1 05/29/2026 PERSONAL&ADV INJURY $ 2.000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 400000 X POLICY ❑ PROJECT ❑ IOC PRODUCTS-COMP/OPAGG S 2,000,00 OTHER' $ A COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $ (Ea accident) 2,000.000 ANY AUTO BODILY INJURY(Pet person) S A OWNED AUTOS SCHEDULED ONLY AUTOS N 602378275 05/29/2025 05/29/2026 BODILY INJURY(Per accident)$ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ ONLY AUTOSONLY (Per accident) UMBRELLA LIAS OCCUR EACHOCCURRENCE $ EXCESS LIAS CLAIMS MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTHER $ AND EMPLOYERS'LIABILITY STATUTE ANY PROPRIETOR/PARTNER/ Y/N E.L.EACH ACCIDENT $ EXECUTIVE OFFICER/MEMBER N/A EXCLUDED?(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 67 S TUSTIN ST,ORANGE,CA 92866 ertiificate of insurance shall provide 30days prior written notice. TU Tfd Il DlgltAly signed by D,i er 2025.0530 APPROVED Ng Uyen 14:18s5-07'00' By Tu Tran Nguyen at 2:17 pm,May 30, 2025 CERTIFICATE HOLDER CANCELLATION CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION RISK MANAGEMENT DIVISION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 20 CIVIC CENTER PLZ AUTHORIZED REPRESENTATIVE SANTA ANA CA 92701 ACORD 25(2016/03) !t)1988-2015 ACORD CORPORATION.All Rights Reserved 31-1769 11-15 The ACORD name and logo are registered marks of ACORD � ACOR& CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYYI 1* � 1 05/29/2025 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 Calhoun&Associates NAME: T N Carmen Ponce NAME: DBA: Integrity Advisors PHONEo.E>zn: 800-500-9799 AIC 714-664-0614 FAX twc.N _ a Nail: 14771 Plaza Drive, Ste C E4AAIL carmen ante rft advisorS.com ADDRESS: 9 y- Tustin CA 92780 INSURER(S)AFFORDING COVERAGE NAICM INSURER A:REPUBLIC INDEMNITY CO OF AMERICA 19739 INSURED William H.Nuesse,M.D.and Mary-Ann Nuesse,D.O. INSURER8; Sunrise Multispecialist Medical Center INSURERC: 867 South Tustin Street INSURER O ORANGE CA 92866 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 TYPE OF INSURANCE R ADDL SUBR POLICY EFF POLICY EXP POLICYNUMBER MM/DWYEWFY MMIDD/YYYYV LIMITS COMMERCIAL GENERAL LIABILITYLi EACH OCCURRENCEDAN $ CLAIMS-MADE OCCUR PREMISES(E occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ :F N'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S POLICY❑ PRO JECT 7 LOC PRODUCTS•COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1 Li ANYAUTO BODILY INJURY(Per pension) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS MIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY P ent __ P $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR Id CLAIMS-MADE AGGREGATE $ DEO I I RETENTION$ $ WORKERS COMPENSATION PER OTH- ANO EMPLOYERS'LIABILITY TATUTE ER A ANYPROPRIETOR/PARTNER/EXECUTIVE Y i N 25601703 08/01/2024 08101/2025 E.L.EACH ACCIDENT S1,000,000 OFFICER/MEMBEREXCLUDED'+ Y❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 El DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached if more space is required) APPROVED By Tu Tran Nguyen at 2:17 pm,May 30,2025 CERTIFICATE HOLDER CANCELLATION City of Santa Ana 20 Civic Center Plaza SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Santa Ana CA,92702 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD i COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31,2025 Member: William H.Nuesse,MD Address: 867 S Tustin Ave Orange,CA 92866 This certificate confirms that, on the date below, the abovtrnamed 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 Medical Specialty Coverage Date Retroactive Coverage Date 13�21 Family Medicine,With Minor April I,2004 February I,2002 Surgery Subspecialty Coverage(Claims made and paid) Current Limits or Llablllty $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 die Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination ofehis coverage. Cooperative of American Physicians,Inc. January 14,2025 Alfred De Leon Date Vice President,Membership Services Mutual Protection Trust APPROVED By Tu Tran Nguyen at 2:18 pm,May 30,2025 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.POLICY NUMBER: 602378275 17238 1st Edition 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 Person(s)Or Organization(s): CITY OF SANTA ANA its officers officials,employees&volunteers 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: 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. 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-ED1 02-19 1 ncludescopyrighted material of Insurance Services Office,Inc.,with its permission. Page of 937238 J7238101 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. F A R M E R S E3306 INSURANCE 1st Edition WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US 05/30/2025 602378275 Effective Date Policy Number This endorsement modifies insurance provided underthe following: BUSI NESSOWNERS COMMON POLICY CONDITIONS-BP 00 09 SCHEDULE Name of Person or Organization: CITY OF SANTA ANA its officers officials,employees&volunteers (If no entry appears above,information required to complete this Endorsement must be shown in the Declarations as applicable to this endorsement.) The provisions of the Businessowners Common Policy Conditions are modified by this endorsement as follows: Condition K.Transfer Of Rights Of Recovery Against Others To Us in the Businessowners Common Policy Conditions is amended by the addition of the following: 3. We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your work done under a contract with that person or organization and included in the products-completed operations hazard.This waiver applies only to the person or organization shown in the Schedule above. 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. E3306-ED1 6-97 Includes Copyrighted Material of Insurance Services Office,Inc.,with its permission. Page 1 of 1 91-3306 E3306101 �" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/30/2025 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 Calhoun&Associates CONTACT NAME: Carmen Ponce DBA: Integrity Advisors (PHONE.,Ext:800-500-9799 FAX No:714-664-0614 14771 Plaza Drive,Ste C E-MAIL carmen mte ri advisors.com ADDRESS: g ty" Tustin CA 92780 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:REPUBLIC INDEMNITY CO OF AMERICA 19739 INSURED William H.Nuesse,M.D.and Mary-Ann Nuesse,D.O. INSURERB: Sunrise Multispecialist Medical Center INSURERC: 867 South Tustin Street INSURER D ORANGE CA 92866 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD MM/DD COMMERCIAL GENERAL LIABILITY L1 EACH OCCURRENCE $ —1 CLAIMS-MADE ❑ OCCUR -PREMISES DAMAGE TO PREMISES Ea occurrence) ccurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ YIEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO JECT ❑ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY ❑ COMBINED SINGLE LIMIT $ Ea accident eANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS uHIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident lul u $ UMBRELLALIAB OCCUR F EACH OCCURRENCE $ u EXCESS LIAB u CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE Li ER A ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N 256017-04 08/01/2025 08/01/2026 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? 1 N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 Digitally signed 00 TU Tr an byTuTran Nguyen Date:2025.10.07 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ' 45 The Waiver of Subrogation applies to the City of Santa Ana, its City Council,officers,officials,employees,agents,and volunteers. APPROVED By Tu Tran Nguyen at 10:45 am,Oct 07,2025 CERTIFICATE HOLDER CANCELLATION City of Santa Ana Attention: Human Resources Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 Civic Center Plaza, CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule State Person or Organization Job Description California City of Santa Ana, Operations of the named insured Attention: Human Resources Department 20 Civic Center Plaza, CA 92701 Santa Ana, CA 92701 The premium charge for this endorsement shall be $250. This charge will be billed at the final audit. WC 00 03 13 1 of 2 (Ed. 04-84) Insured Copy ©1983 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Republic Indemnity Company of California Company Number 27561 Insured William H Nuesse MD and Mary Ann Nuesse Do, a Medical Corp Policy Number 256017-04 Endorsement Number 12 Endorsement Effective August 01, 2025 Printed On October 03, 2025 Countersigned by WC 00 03 13 2 of 2 (Ed. 04-84) Insured Copy ©1983 National Council on Compensation Insurance.