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2020/08/21 American Forensic Nurses, Inc. Certificate of Liability InsuranceAMER103 OP ID; ACpRO CERTIFICATE OF LIABILITY INSURANCE DATE 1261202YY) olrz6r24z1 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 626-914-99" CONT, CT Lori A. Patterson NAM Jackson & Jackson Insurance PHONE 626-914-9944 FAX 626-914-1040 302 E Foothill Blvd (AFC, No, E>es ; AIC. No): San Dimas, CA 91773 E-Xffl6a4.loriawinsurance.com INSURER A.. James River Insurance Company 12203 INSURED American Forensic Nurses Inc., INSURER B : State Compensation Ins, Fund 35076 P.O. Box 1625 La Quinta, CA 92253 INsuRERc; INSURER D : INSURER E: INSURER F : 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 I TYPE OF INSURANCE ADD L SUBS'WVDPOLICY NUMBER POLICY OFF POLICY EXP LIMITS A I X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR 100063557-6 08/21/2020 =21/2021 DAMAGE TO RENTED 100,000 X X PREMISES IEa oecurreneel $ AGGRE TE LIMIT APPLIES PER: IEN'L X POLICY JEST LOC OTHER: A AUTOMOBILE LIABILITY ANY AUTO X X ID0063557-6 OWNED SCHEDULED AIUTOS ONLY AUUTµOpSy��p AUS ONLY X AUTOS OfJLY UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DIED I I RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N X 9225103-2021 OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) A Professional Liab Retro 11/30/2004 08/21/20201 08/21/2021 BODILY 01/31/20211 01/31/2022 1 I E L. DISEASE 08/21/2020 08121/2021.Ea Claim I Aggregate pp c PT1Ry OF TlpyS 1 LOCpT10NI1 HICLES ,(AC RD 101. Addl1{ppal R�pprks g�pgdule a de attpched if more space la required) i MLTllfee F'OIIce E7aa{]ai[ment; orenslc SerVIC85. ! I1B C F[jl p1 MenIT@L' afld is officers, officials, employees, agents and authorized volunteers are ncluded as additional insureds, with regard to general liability, )rofessional liability and auto liability of the named insured, per attached orm AP2009US O4-10. Waiver of subrogation included per form (over) City of Menifee 29844 Haun Road Menifee, CA 92586 LIMIT 1 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIIZ�ZEDREPRESENTATNE I& ow LQtu�—_ _ ACORD 25 (2016/03) 01988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD American Forensic Nurses, Inc. Policy #00063557-6 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED AS REQUIRED BY WRITTEN CONTRACT This endorsement modifies Insurance provided under the following: ALL COVERAGE PARTS SECTION II —Who Is An Insured Is amended to include any person or organization you are required to include as an additional Insured on this policy by written contract or written agreement in effect during this policy period and executed prior to the "occurrence" of the "bodily Injury" or "property damage." The insurance provided to the Additional Insured under this endorsement is limited as follows: 1. The person or organization Is only an additional insured with respect to liability arising solely out of "your work" or "your product" which is imputed to the Addltlonal Insured. 2. In the event that the Limits of Insurance provided by this policy exceed the Limits of Insurance required by the written contract or written agreement, the insurance provided by this endorsement shall be limited to the Limits of Insurance required by the written contract or written agreement. This endorsement shall not increase the Limits of Insurance stated in the Declarations. 3. This insurance does not apply to "bodily injury" or "property damage" arising out of "your work" or "your product" included in the "products — completed operations hazard" unless you are required to provide such coverage by written contract or written agreement but only for the period of time required by the written contract or written agreement and only for "bodily injury" or "property damage" that occurs during the policy period arising out of "your work" or "your product'. 4. Any coverage provided by this endorsement to an Additional Insured shall be excess over any other valid and collectible insurance available to the Addilional Insured whether primary, excess, contingent or on any other basis. 5. Where no coverage under this policy shall apply for the Named Insured, no coverage or defense shall be afforded to the Additional Insured. 6. This insurance does not apply to "bodily Injury" or "property damage" arising out of the sole negligence of the Additional Insured. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP2009US O4-10 Page 1 of 1 American Forensic Nurses, Inc. Policy #00063557-6 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON CONTRIBUTORY ENDORSEMENT This endorsement modifies Insurance provided under the following; ALL COVERAGE PARTS Any coverage provided to an Additional Insured under this policy shall be excess over any other valid and collectible insurance available to such Additional Insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement speclflcally requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5031US O4-10 Page 1 of 1 American Forensic Nurses, Inc. Policy #00063557-6 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CARFEULLY. WAIVER OF SUBROGATION AS REQUIRED BY CONTRACT This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS The Company agrees to waive any right of recovery against any person or organization, as required by written contract, because of payments we make for injury or damage which is limited to liability directly caused by "your work" which Is imputed to such person or organization. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5004US 11-06 Page 1 of 1 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS 9225103-2021 RENEWAL SC 9-88-17-94 ROME F OFFICE SANAN FEtA1t11CISt;CI EFFECTIVE JANUARY 31, 2021 AT 12.01 A.M. PAGE ALL EFFECTIVE DATES ASE AND EXPIRING JANUARY 31, 2022 AT 12.01 A.M. AT 12;01 AM PACIFIC $TANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME AMERICAN FORENSIC NURSES, INC PO BOX 1625 LA QUINTA, CA 92247 l4r. RAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN INJURY COVERED BY THIS POLICY. VE WILL NOT ENFORCE OUR RIGHT AGAINST THE JPZRSON OR ORGANIZATION NAMED IN THE SCHEDULE, THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM 'US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00t OF THE TOTAL POLICY PREKIU H . SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WR17TEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENT$, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED, NOTWNG ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUES AT SAN FRFRANCISCO. fly •� AUTHORIZED REPRESENT IVE SCIF FOAMS to2t7 IgEv.i-:t0141 JANUARY 31, 2021 1 OF 1 ef- PRESIDENT AND CEO 2572 4LD [N' 217