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Home My WebLink AboutU.S. HEALTHWORKS 2A - 2004 AGREEMENT TERMINATION Please complete this form when the attached agreement is no longefai effect, Return form to the Sr. Deputy Clerk of the Council (M-30). Call 647-5238 if you have airy questions. The agreement with U-s , �L No. A ---170 was completed on p t ap)C , and final payment has been made. A - 2o0z-I51 (2.) cart, Department: rl •�C 4 A -20o9-V2o- 02 Signature: C A-2oo6- ib3 Date: 0/1-- City of Santa Ana Revised 8-7-03 Clerk of the Council A-.;JOO -V-I,(V-CJ.i&-> " INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES 9-1-01 CLERK OF COUNCIL DATE: y- 17-(Jlf SECOND AMENDMENT TO CONSULTANT AGREEMENT t'Pb L~- 6r107tW) THI~ShCOND AME DMENT TO AGREEMENT #A-2002-I57, is entered into on the 21L day of ,2004 by and between U. S. Healthworks, a California corporation (" onsult t") and the City of Santa Ana, a charter city and municipal corporation of the State of California ("City"). Recitals: A. The parties entered into Agreement #A-2002-I57, dated August 19,2002, (hereinafter "said Agreement") by which Consultant has provided comprehensive physical examinations for the Fire Department. B. In accordance with the terms and conditions of said Agreement, the parties wish to amend the Scope of Services, extend the term of said Agreement and increase the compensation to pay for services during the extended term. Wherefore, in consideration of the covenants contained in said Agreement, and subject to all the terms and conditions of said Agreement, except those amended in this Second Amendment to Consultant Agreement, the parties agree as follows: 1. Section 1, SCOPE OF SERVICES, shall be amended to require that Consultant shall provide comprehensive physical evaluations for sworn Fire Personnel sworn Peace Officers, as set forth in Exhibit A-I, attached hereto. 2. Section 2 a., COMPENSATION, shall be amended to read as follows: "City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit A. The compensation to be paid under this Agreement shall not exceed $47,000.00, per fiscal year, during the term of this Agreement." 3. Section 3, TERM, shall be amended to read as follows: "This Agreement shall commence on August 19, 2002 and terminate on June 30, 2005, unless terminated earlier in accordance with Section 12, below. The term of this Agreement may be extended upon a writing executed by the Fire Chief and the City Attorney." 4. Except as amended hereinabove, all terms and conditions of said Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Second Amendment to Consultant Agreement on the date and year first written above. CITY OF SANTA ANA ATTEST: ~..~/ . ~MRlClAE<;lliAty -- -(J Clerk of the Council ~z/ . AVIDN.REAM ~ City Manager APPROVED AS TO FORM: JOSEPH W. FLETCHER City Attorney By:M~A,"jkPoly Lau Sheedy . Assistant City Attorney CONSULT ANT IC ELLE HARRISON Industrial Accounts Coordinator ACO~ CERTlFlCATE OF LIABILITY INs~CE 1 ......~ ~r-= 11/CSJOl -..... T/lUO cnnncr.n IS lS$lJlIll AS A MAnEll or IN"D~'JION Qfft.y GALLAGHER KULTHCAllE I1'Isl.1\lANCI! seRVICJ!S,INC .&ND c~ NO RICBn urOJlj IlP' aalJllCATIl 1l0Ulf:R. "TIlI:S 0N5 81U/1.lU.AKE n.A.ZA, SQITI'. 2000 cuTlFICATll DOES NOT..-. EXJ'D'IID OIIl...LnII tHE CO\ld4Ct: 2000 WEST SAM llOUSTOfoJ pAIU(.WA Y SOU'lJi .nOADIDBY nn; I'OLICIt:lI ~~o,.,. HOUSTON. n: 77042.3622 100-1]].441. LN~ERS AFFOfIIlING COVERAGE ..- 1II1\1JD .' H,U.TfOIID CASUALTY 1N5Vf>>ICE COMl'ANY US HEALTHWOJ.KS, INC. "lUll'" 1Wtn:ClU) flllE lNSUUHC:ECOMl'jOI'(Y l~S\ NOIlni POIN. I'ARK.W^Y, SUIT/! 1j(J ..lOJIIJ c, IWtTFONlIN~CQ)ollANY or 1liE l\oClPWEST ALPHME't"\'.... G.... 30005 "!Wa'" l1IE DOCTOIlS COMI'ANY ...uua ,. t);J t1l! IQUcas or ..S\lMHCE USnD'u.ow KA'" IWllSWEll ro l1lIll'IUIEll lol4lCEll AtOYI f(lf. 11tI101.IC'i r!AIOIllNIXC..1Dl, oonrmer_o ~ ...~, ...- Of, ~_. QI OF "'"' CGtIJIlI'CfOJ 0_ ooCOMDtr wml mncr 10 1o'lGQI nPlo CDol'lflC4l'E ....Y IE /$$&1I!D OJ. "'^" !'Pf_ ~~~.:'I'nlllrolJl;lU~~~."" _IN.SiUllZ,;r l'OAI.L '11& rtlMS.IXe>.USIO'" N'II'(.<lIQllOti1 aJ .ualtoUCllI.. "OOUC..A.l'I a&Ao"f vEMD C\..llJIiI(I, - P<lIJCYN_ -....- PG:..~~NaM UIlITS ,.. nKOI_NCf. ." iGENEJW.lJofAl~'1Y w:a~ , 1,000,000 A ............. .-m' FtftI, DAMAGI.-. _~I J 300000 l:......-Eil-' M2DIJaWr-~ , 10.000 pDSQNALAlIl'f l'IIAn'.y S 1.000,lJllO 61un<<JV5lZ3 O9/IJ1101 09ill1104 ~_GA18 I 3 000,000 ~r;:-~'" JII.l>>UC;II- mreot AGO J l,ClQO,OOO 1IC1'( ~ ~II.RLI""'" ~SIW(:UlJ)GT . 1.000,00(1 - Kl#'fAUTO -) B 1 AU. oWM!D At11'OS ~~~.~lUI.Y J loll. SCIIEDUU!IIAL'1'OS _oW1V5 611JWUT"12 otIOtlllJ 09i01/OO ~YlMl\IO." J NI^ :x MO'W..owMiD AoU'tOl _.wi) '- I- f~~lWCAG2 S l"IA UOIIO.,.... :;"_V... Ace_ S loll... ~""UllrO NlA w... NlA otllU J1Wl MAt'! . HI... AUlOOtlI.Y. MX 5 /II'" ~IUT1' ~"Oa:UaJDICl' I HIA ......... ~...... .(lGUc;..U . NiA KIA "'I" foliA . NlA IIIIlUCTIIU J HIA ~~"w_ , NTA YIJD' ......un' "~W~ll:" c u,~""...... I I.DOll,OOO &1 WNt-ISS320 119IOIIOJ 09i01104 f"J. JI,SI..ta - ok 1QlM018 . 1,000,000 1o.........-....lCy...... . l.lIOO.aao Ol_ D MEJ>iCAJ.. pJ.OfESSlOI'IAL 09101/0] S 1,000,000 I'EJlINCIOENT lJABll.ITV.CLAIMS w.DE 00612\0 0910'.0& I~~'OOO,IIOO ~U<iA~" '" .A. ItIlC:llllfYlOJl 01' DftJIIA.....M.GCA.'IIQII'fINS.ItIA.-:JQ.\nII'01III1 .0DI1l'''' IN-.cII,,,,,I,IPECW. ....,.,.IIE*. 1Jj, IllO E.UT IDl!QI.. SAJoIl'A.ANA. CA 91'0\ CiAllFlCATE IIO\.DUo, IT'S OFF1CP5. AGENfS.AND "OtutmiPJ.u! _0 AS 4Il0rrlOl'IAL INSUUilSAS Wn.crs TO OiNJU,LUAlla.m'. CERTIFICA IE HOLDER AI....~IN$UltK1Jr:;;;-- ciilCeLU nOM 1eOVU.n DJ'... A._VIo.It.S~ rauclIIJr&C'".,.,aao ..NM THqiI'laIt"lQll Crn' Of So'oNT^~ eA" 1'1fINO". .,. VSUPC ......,... WD.J,. .........woa 100 Na.Uo ...Jl. !DAd ~ 20 CMC amEll PLAZA ..onca "' ... cra'NICAJI WIIlKIl ".... ... 'fW u.n,"" rAUIU 10 illiG 10 IW-L sAW'... N1h. C/It. 92.101 " - '. ~ ~ IfO 9....1IDN .. J.IIlIlfD.aY' Of ""., .... VfOfI .. CMlUJlIo m ..Q)m a... I .L1JI 1"'\'" ...__ ...-. ....J 112- .. -. /7' -Y. A ...coU2S$(I"ll l ,u.r;. '7 _....~.,- ._~'-'" li'I"cOIlll COIlPOJIA 1107< ..If ;, ,., GRLLRGHER HERLTHCRRE Fax:713-365-64S8 SR>lTA ~ R1Sl< MGMT. .714-647.<;311 Nov 62116:14 P.02 Nov () 2003 :0& POL fWt GRLLAGHER HEALTHCARE Fa~:713-36S-6A89 ~lA RNA RISK MGMl. F4IIr14-647-S311 Nov 6 ~ 16:14 P.03 NOli 62003.:07 P.03 IMPORTANT If Ill. .....;f...... hold...;, ... ADDmoNAL lIISUlUlD. Ibt ,.I~iec) ""'II be ..dorscd. A .......,.., ClIl dlis .cmr",... d... nol..... ';cllIa 10 dlc .otIili<>lc IIoldl:t ,oll'. <If fI1CIl ..""'....111(.) If SUBROGAnON IS WAIVED. ...~i." 10 l/lO t..".. -' .lI')iIIti.... .rdl. polit~. ,...... po~_...y "'I.'" III ~ A "........ .... !hit _if 1_ <Iou Dol _rv l1,hl.I '0 Ill. ....ili'"'" bolOCr .. m. of l'I4I"',I<'II'III('I. DISCLAIMER The C5/1iIi_ ., 1aI..__ CIG ... .......... .ide of 1l1i11\n1 .OOS 0" """ci_ .....n<< .......... lIoc iswllII i_('). ~ topNlN!Ilwo.. .r ploda<.., -.4 d\t ~6t...IIoUet. .., do" it ~l!lIIIi..ly .f ."OIivdy _d, IIllmld I\x liter Il\t '''''0&< olJord.d by Itw; politjc$lostod ....... , ,.511ml GR..LAG!-[R !-[~L TI-().RE Fax:713-365-6488 . Nov 6 20~ 16;14 P.04 . COMMERCIAl GENERAl LlABltJTY rOLlCV NUMBER: 61 UEN UV5523 CHANGE NUMB2R., CO 1 THIS ENDORSEMENT CHANGES THE pOLICY. PLEASE READ IT CARERJU,V. ADDITIONAL INSURED. DESIGNATED PERSON OR ORGANIZATION TIlls IIIldOlSlll'l\ll1\l modifies insurallOll provid&d under the fdloWilltJ; II> ~ COMMERCIAL GENERAl LIABIUTY coVERAGE PART '" '" . o ... ~ SCHEDULE '" on In ~ N.-...~orOl'P'~: .... '" .. o City of Santa Ana, it'. officers, agents, employees. and volunteers '" o o . =" = :: == "". is ;; .- == -= !:: ~ ~ .... :::;:;:: - - - - - - ..., - ... !- 1!5 - - ...... ~ - = (If no ontry appears aboVll, inlormatiDn mqulf9d 10 complete lhis endon;emellt IMII be shawn in lhe DedBl'alions as applicabllllo \IIis lI/IlWsemenL) WHO IS AN INSURED (Sar;Uon II) is amll\d8C11o Inoludll- an insurllCl 11\8 pSI'SClf1 or organization shawn in !he Sc:l\8duls as an insured but only with raspeel 10 liabilily arising out of YOllr oparaliolls or premise& owroed by Cl' r8llted to yoU. ~a ,rlJ/ ~;~: rc::::1'~7 .,.,.,--..---- CG20261185 COpYrtgt1l, Insurance lOarvic&5 Otlioe..lnc., 19&4 ACORD,. CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDNVYY} 9/1/2005 PRODUCER 50 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Arthur J. Gallagher & Co. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License #0726293 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 505 North Brand Blvd, Suite 600 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Glendale, CA 91203-3944 Phone: 818-539-2300 Fax: 818-539-2301 INSURERS AFFORDING COVERAGE NAIC# "_.~-- IINSURERA: INSURED Hartford Casualty Insurance Company 29424 U.S. HealthWorks, Inc. INSURER B: Hartford Fire Insurance Company 19682 3655 North Point Parkway, Suite 150 Hartfo~d Insurance Company of the Midwest 37478,._ Alpharetta, GA 30005 INSURER c: A - ;).003- ;;1.;;2.'1-0 "'- INSURER 0: , INSURER E" COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. [mS'R ADD'LI - POLlCYEFFEC1WE POLICY EXPIRATION I I TD i':'..o...1 POLlCY NUMBER .......... ~ENERA;L LIABILITY 72UENUM8309 'X COMMERCIAL GENERAL LIABILITY 1 r::-lX ~~ CLAIMSMADE l.".1 OCCUR - LIMITS 1,000,000 300.000 09/01/05 09/01/06 $ $ EACH OCCURRENCE ~~~~~~~?E~~~~~r~()ce\ A 10,000 MED EXP (Anyone person) 1,000,000 3,000,000 3,000,000 PERSONAL 8. ADV INJURY GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ COMBINED SINGLE LIMIT $ (Eaaccidenl) BOD\L Y INJURY $ (Per person) BODILY INJURY $ (Per accident) PROPERTY' DAMAGE $ (Peraccidenl) AUTO ONLY _EAACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EACH OCCURRENCE $ AGGREGATE $ $ $ $ ~'LAGGRE~E LIMIT AP~S PER: I I POLICY I I ~!39; I X I LaC ~TOMOBILE LIABILITY ~ ANY AUTO ~ ALL OWNED AUTOS ~ SCHEDULED AUTOS ~ HIRED AUTOS ~ NON-OWNED AUTOS - 09/01/06 72UENUM8309 09/01/05 B 1,000,000 GARAGE LIABILITY ~ ANY AUTO '~ESSIUMBRELLA LIABILITY ~ OCCUR D CLAIMS MADE =:} DEDUCTIBLE x-j ~ETENTION $ 10 000 C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORlPARTNERlEXECUTlVE IOFFICERlMEMBEREXCLUDED? ~P~~~~~~~VIS~ONS below OTHER 10,000,000 10,000,000 09/01/06 09/01/05 72XHUTQ5969 A XiWCSTATU- I 10TH- I TORY L1MIT.c; I FR E.L. EACH ACCIDENT $ 1,000,000 ~L._~I~EA_S~_~_~~?LOY~ ~_ ____1 ,O~O,O~~ I EL DISEASE _ POLICY LIMIT I $ 1,000,000 72WNMG3070 09/01/05 09/01/06 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *Except 10 days notice for non-payment of premium. RE: 1530 EAST EDINGER, SANTA ANA, CA 92705 /h~~:/ ~/ {r.Le' (1'1 1./ :::::. .' CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ~C-~~ '---- @ACORDCORPORATION1988 City of Santa Ana 20 Civic Center Plaza Santa Ana, CA 92701 ACORD 25 (2001/08) , ACORD~ CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDNYVY) 813112005 PRODUCER 50 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Arthur J. Gallagher & Co. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License #0726293 HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 505 North Brand Blvd, Suite 600 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Glendale, CA 91203-3944 Phone: 818~539-2300 Fax: 818.539-2301 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Hartford Casualty Insurance Company 29424 U.S. HealthWorks, Inc. INSURER 6: Hartford Fire Insurance Company 19682 3655 North Point Parkway, Suite 150 INSUAERC: Hartford Insurance Company ofthe Midwest 37478 Alpharetta, GA 30005 INSURER D: INSURER E: COVERAGES 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 iHE iEAMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I~~ r.!:D' ~DD nD POLICY NUMBER POUCYEFFECTlVE POt.ICYEXPIRATJON UMITS A f.E5NERAL UABIUTY 72UENUM8309 09/01105 09/01106 EACH OCCURRENCE , 1,000,000 X COMMERCIAL GENERAL LIABILITY ~~~~~~S YEa oce ranee $ 3OQ,OOQ I CLAIMS MADE 0 OCCUR MED EXP (Anyone ""'rson) $ 10,000 ~ PERSONAL & ADV INJURY $ 1,000,000 ~ GENERAL AGGREGATE $ 3,000,000 n'L AGG:Er~E LIMIT APFilIPER: PRODUCTS -COMP/OP AGG $ 3,000,000 POLICY 1~J"'p,: X LOG B ~TOMOBILE LIABILITY 72UENUM8309 09101105 09/01106 COMBINED SINGLE LIMIT {Eaaccident} $ 1.000,000 ~ ANY AUTO ~ ALL OWNED AUTOS 60DIL Y INJURY $ ~ SCHEDULED AUTOS (Per parson) ~ HIRED AUTOS BODILY INJURY $ ~ NON-OWNED AUTOS {Peraeeiden,> PROPERTY DAMAGE $ (Per accident) ~~GEUABIUTY AUTO ONLY. EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A ~~SSlUMBRELlA LIABILITY 72XHUTQ5969 09/01/05 09101106 EACH OCCURRENCE $ 10,000,000 X OCCUR D CLAIMS MADE AGGREGATE $ 10,000,000 $ ~ ~EDUCTIBLE $ X RETENTION $10000 $ C WORKERSCOMPENSATlON AND 72WNMG3070 09/01/05 09101/06 X!T~:;;~J~IIt~ J IO;,!;!- EMPLOYERS' LIABILITY 1,000,000 ANY t" ROPRiETOR/PARTt.lER/iOXCCUTIVE: E.l. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE - Ell. f;MPLOYEE $ 1,000,000 ~P~~~~~~~~bNS below E.l. DISEASE - POLICY LIMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES J EXCLUSIONS ADDED BY ENDORSEMENT f SPECIAL PROVISIONS "Except 10 days notice for non-payment of premium. RE: 1530 EAST EDINGER, SANTA ANA, CA 92705 "--/-<>/1' . ~ / "'~ ,~' .J- /-_".~I-:~~_/ 11< /' ' . #'/ , CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED PQUCIES BE CANCELLED BEFORE THE EXPIRATION OATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITlEN City of Santa Ana NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO so SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 20 Civic Center Plaza REPRESENTATIVES. Santa A~a, CA 92701 AUTHORIZED REPRESENTATIVE ~cR- '- ACORD 25 (2001108) @ACORDCORPORATION19~ ACORD,. CERTIFICATE OF LIABILITY INSURANCE I DATE{MMlDDIYYYY) 101712004 PRODUCER (800) 733-4474 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION GALLAGHER HEAL THCARE INSURANCE SERVICES, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ONE BRIAR LAKE PLAZA, SUITE 2000 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 2000 WEST SAM HOUSTON PARKWAY SOUTH ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. HOUSTON, TX 77042 INSURERS AFFORDING COVERAGE NAlC # INSURED INSURER A: THE DOCTORS COMPANY 18083 U.S. HEAL THWORKS, INC. INSURER B: 3655 NORTH POINT PARKWAY, SUITE 150 INSURER C: ALPHARETTA, GA 30005 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOlWITHSTAN01NG 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I~i'~ ~~~L p~;~y ~:~~~E POLICY EXPIRATION LIMITS TYPE OF INSURANCE POLICY NUMBER DATE MM/DDNY ~NERAL LIABILITY EACH OCCURRENCE NIA COMMERCIAL GENERAL L1ABLITY ~~~~~~~E~E~~~~RENCE'" N/A - =.J CLAIMS MADE DOCCUR MED EXP (Anyone pElrwn) NIA PERSONAL & AOV INJURY N/A GENERAL AGGREGATE N/A ~N~L AGGREA ~~': APp~r PER: PRQDUCTS _ COMP/OP AGG N/A POLICY JECT LOC ~TOMOBilE LIABilITY COMBINED SINGLE LIMIT N/A (EaaOOdent) - ANY AUTO - ALL OWNED AUTOS BODILY INJURY N/A (Per person) - SCHEDULED AUTOS - HIRED AUTOS BODILY INJURY N/A (Peracddent) - NON.OWNED AUTOS PROPERTY DAMAGE N/A (Peracdclent) ~AGE L1AS'L1n AUTO ONLY _ EA ACCIDENT NIA ANY AUTO OTHER THAN EAACC N/A AUTO ONLY: AGG N/A EXCESS/UMBRELlA LJABJ1.JTY EACH OCCURRENCE N/A =::J OCCUR 0 CLAIMS MADE AGGREGATE N/A N/A =i:DUCT"" N/A ETENTlON NIA WORKERS COMPENSATION MID I we STATU., I <\ OTH. EMPLOYERS'LIABJLJTY )( TDRY LIMiTS X ER ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT NIA OFFICER/MEMBER EXCLUDI::D? N/A ~ yes, describe under EL DISEASE: _ EA EMPLOYEE: SPECIAL PROVISIONS below E,L. DISEASE - POLICY LIMIT N/A OTHER 1,000,000 PER CLAIM A MEDICAL PROFESSIONAL 69727 05101105 05101106 3,000,000 ANNUAL AGGREGATE LIABILITY - CLAIMS MADE DEDUCTIBLE $100,000 PER CLAIM DESCRIPTION OF OPERATlONSILOCATIONSIVEHICLES/EXCLUSIONS ADDEO BY ENDORSEMENT/SPECIAL PROVISIONS MEDICAL PROFESSIONAL RETROACTIVE DATE: 1010111995 ... ^ - ,<f'/ It 1/ ", ^", 'p.Jt \';t" { 11 "'-. ,,;,. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE;: ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF SANTA ANA DATE THEREOF, THE ISSUIK13 IKSURER WILL ENDEAVOR TO MAIL .....H.. DAYS WRITTEN NOTICE 20 CIVIC CENTER PLAZA TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, aUT FAILURE TO 00 SO SHALL IMPOSE NO SANTA ANA, CA 92701 OBLIGATION OR LIABILITY 0' AN' KINO UPON THE INSURER:, ,,. AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATIVE 'c-';7 /52. r~ -;) ''''- ~------------ ,~L ,~~,-._'..~- -"--- ACORD 25 (2001108) @ACORD CORPORATION 1988 ADDITIONAL INSURED ENDORSEMENT I C Hartford Casualty Insurance Co.; Hartford Fire Insurance Co. nsurance ompany This endorsement modifies such insurance as is afforded by the provisions of Policy # 72UENUM8309 relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92702; its officers, ernployees, agents and volunteers are narned as additional insureds ("additional insureds") with regard to liability and defense of suits arising from the operations and uses perforrned by or on behalf of the narned insured. 2. With respect to claims arising out of the operations and uses perforrned by or on behalf of the narned insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect to the additional insureds, this insurance shall not be canceled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92702. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective September 1,2005 , this endorsement form as a part of Policy # 72UENUM8309 Issued to u.s. HealthWorks, Inc. Countersigned by resentative "./ ~/ ~,.), 0.. /, )j, 0/(.__ ~I.::,-,_~'i:(fl_.</__':~__' . ~/ ACQBJ:t CERTIFICATE OF LIABILITY INSURANCE I i i DATI' {MM,POIY)''(Y) 10/19!2006 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, PRODUCER Arthur J, Gallagher & Co. License #0726293 505 North Brand Blvd, Suite 600 Gler;t:Jale, CA 91203.3944 Phone_ 818,539-2300 rme 818,.539-230, INSURERS AFFORDING COVERAGE NAIC# IN$'JRED U.S. HealthWorks, Inc. 3655 North Point Parkway, Suite 150 A!pharetta, GA 30005 INSUREr< A _,!j~~~?_~i:!,!:iE:.,l0.~~E~0,~,~_S~9!':"P~ ny INSUR,,;:'l a Hartford IP,SJRER D IN$JRFRf COVERAGES THE POLICiES O~ iNSURANCE LISTED BELO'N H/IVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERiOD INDIC,\TED NOTVi!THSTANDING ANY REQUIREMENT, TERM OR CONDITiON Or: ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE r.,'AY BE ISSUED OR MAY PERTAIN, THE !NSURANCE- AFFORDED BY THE POLJCIES DESCRI8ED HEREIN JS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLlCES, AGGREC',ATE LIMITS SHOWN r.1AY HAVE BEEN REDUCED BY PAID CLAJMS. ^ " 72UENUM8309 LIMITS 09/01106 09/01/07 _,~i:~gg;::!,~H~,I\PVI~.JURY q?t_~:")~LA:q<:;!'lS(;ATC 300,00G 10,000 '1,000,000 3,000,000 3.:;)00,'060 CCCUR I'~/(r ,;"'p:d~S "iiiK A POliCY 09/01107 1 ,000.000 ANY AUTO A.LlCWVNE~AJT()..,> BODilY IN...'URY lPeqxvUJI! X SC!,EOU",PCAUTOS X X H)I~f.:; AUTOS BO(}ll Y IN.;;JRY li'tHaccid(l1)1; I\ON.owr;;:[;AUros GII.:RAGE LIABILITY AuTOO....L Y .f:.AACClQEN1 ANY Al!f(, OTHER'rH^," AiJTOONLY G ,_ €XCESS!iJMBREL ~~1~6IL1T Y 09/0'1/06 09101;07 X OCCUR : 0_AIM$ MADE ~~~~::;;;:~,!E D~DUCT-i>:~E X R[TF'H'O'1 S 10000 ^ WORl{ERS COMPENSATION ANO EMPLOYERS' LlABIUTY 72WNi',.1G3070 09(0 1 1lJ6 09;01/07 X ~,::L^, ~t:Cl1 ACCIDeNt is ~" YSEASE. ;'OUCY!.i'tiT 1,000,000 1,000,000 OTHER - .----.- .-- DESCRIPTION Of' OPERA nO~lS.' LOCATIONS i VEHICLES! EXCLUSIONS AOoeo &V ENDORSEMENT I SPECIAL PROVISIONS 'Except ~o days notice for r,on-poyrr)l;ml of premium The City 01 Santa Ana. 20 Civic Center Plaza, Santa J\na, California 92;'0'1. its officers, employees. agents volunteers and represontatives are named as additior,QI insureds with regard to liability ar:d defense of suits arising from the operations and uses performed by or on behalf of the namBd ifl$!Jred. CERTIFICATE HOLDER CANCELLATION 20 OAc Center Pklza S.an:",1 Ana. C/\ 92701 SHOULD ANY OF THE ABOVE OESCRlIlEO POLICIES 6f CANCELLED BEFORE THE EXPlRA TlON OATe THEREOF, THE ISSUING INSUReR WILL XXXXXXl<.XXXXMAlt. ,,,;?St,, DAYS WR:rrTEN ~~:pfi Tp THE CERTifICATE HOLOER NAMEO TO THE lEFT, XXXXYJ0lXXx.xXXXXXXXXXXXX l.iJ...!:xiidXyy'XXJ(xXXXXXX:XXXXXXXXxYJOC';XXXXXXXXXXXXXXXXXXXXX;<.XXXXXXXXXxxxx.>: XXYJ;XXXXMXXXXX AUTHORIZEO REPRESEtHATlVE City of Santa An;) City of Santa An~l Fire DepiOrtmeh! A:!ll'lltb'VtH::I AS '1'0 ~ ACORD 25 (2001108) @ ACORD CORPORATION 1988 L. c, ADDITIONAL INSURED ENDORSEMENT Insurance Company Hartford Fire Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # 72UENUM8309 relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92702; its officers, employees, agents and volunteers are named as additional insureds ("additional insureds") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2 With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect to the additional insureds, this insurance shall not be canceled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92702. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective 911106 - 911107 Policy # 72UENUM8309 Issued to u.s. Healthworks, Inc. , this endorsement form as a part of Named Insured Countersigned by ~- Authorized Representative ['0 ]i'01~M ~~/ ,_ ~'ll L. L Urii Stitt Sheedy \<,I~li';H