CONCERTA MEDICAL CENTER (OCCUPATIONAL HEALTH CENTERS, INC)

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AGENCY CUSTOMER ID: CONCGRO-01 LOC#: ,a`oRo ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Graham Company, Occupational Health Centers of California, A Medical Corporation POLICY NUMBER dba Concentra Medical Centers 5080 Spectrum Drive, Suite 1200 West Addison TX 75001 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Continental Casualty Company-Policy#HAZ 4032244600-10; Effective 1/1/2024-1/1/2025- $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Columbia Casualty Company-Policy#HAZ 4032244614-10; Effective 1/1/2024-1/1/2025- $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Continental Casualty Company-Policy#HAZ 4032244628-10; Effective 1/1/2024-1/1/2025 -$500,000 Each Medical Incident/$1,000,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Columbia Casualty Company-Policy#HAZ 4032244631-10; 1/1/2024-1/1/2025- $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE-Continental Casualty Company-Policy#HAZ 4032244659-10; 1/1/2024-1/1/2025- $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions. WORKERS COMPENSATION-Occupational Health Centers of California,A Medical Corporation-Liberty Mutual Insurance Corp.-Policy #WA5-63D-510199-314; Effective:4/1/2024-4/1/2025 WORKERS COMPENSATION-Occupational Health Centers of Southwest, P.A.-Liberty Insurance Corp.-Policy#WA7-63D-510199-404; Effective: 4/1/2024-4/1/2025 WORKERS COMPENSATION-Occupational Health Centers of Southwest, P.A.-Liberty Mutual Insurance Corp.-Policy#WC5-631-510199-254(WI); Effective:4/1/2024-4/1/2025 ADDITIONAL WORKERS COMPENSATION POLICIES: OHC of Arkansas—Liberty Insurance Corp.-Policy#WC7-631-510199-284; Effective:4/1/2024-4/1/2025 OHC of Southwest(AZ/UT)—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-244; Effective:4/1/2024-4/1/2025 OHC of Delaware—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-334; Effective:4/1/2024-4/1/2025 OHC of Georgia/Hawaii—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-384; Effective:4/1/2024-4/1/2025 OHC of Illinois—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-414; Effective:4/1/2024-4/1/2025 OHC of Louisiana—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-294; Effective:4/1/2024-4/1/2025 OHC of Michigan—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-274; Effective:4/1/2024-4/1/2025 OHC of Nebraska—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-374; Effective:4/1/2024-4/1/2025 OHC of New Jersey—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-264; Effective:4/1/2024-4/1/2025 OHC of North Carolina—Liberty Insurance Corp.-Policy#WC7-631-510199-344; Effective:4/1/2024-4/1/2025 OHC of Southwest(KS)—Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-424; Effective:4/1/2024-4/1/2025 Therapy Centers of Southwest I, PA(OR)-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-394; Effective:4/1/2024-4/1/2025 Therapy Centers of South Carolina, PA-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-304; Effective:4/1/2024-4/1/2025 OHC of Minnesota-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-454; Effective:4/1/2024-4/1/2025 OHC of Alaska-Liberty Mutual Fire Insurance Company-Policy#WC2-631-510199-444; Effective:4/1/2024-4/1/2025 CYBER LIABILITY- Arch Specialty Insurance Company-Policy#NPL2001106-00; Effective: 11/25/2024-11/25/2025-Limit:$10,000,000 EXCESS CYBER LIABILITY-Homeland Insurance Company of New York-Policy#720002431-0000; Effective: 11/25/2024-11/25/2025- Limit:$10,000,000 Excess of$10,000,000 CRIME COVERAGE—National Union Fire Insurance Company of Pittsburgh, PA—Policy#02-173-18-50, Effective 11/25/2024—1/1/2026—Limit$10,000,000 Coverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured,but only for professional services performed for or on behalf of the above Named Insured. RE: OHC OF CA/CMC HAS AN AGREEMENT UNDER#A-2019-006 TO PROVIDE MEDICAL SERVICES TO THE EMPLOYEES OF THE NAMED CLIENT. CITY OF SANTA ANA, ITS OFFICERS,AGENTS,VOLUNTEERS AND EMPLOYEES are all included as additional insureds on the above General Liability, Auto Liability and Umbrella Liability Policies and coverage shall apply on a Primary and Non-Contributory basis if required by written contract. Prior to loss,and if required by written contract,Waiver of Subrogation is provided on General Liability,Auto Liability, Umbrella Liability and Workers Compensation Policies for work performed under contract if permissible by state law. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD