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2019/08/21 American Forensic Nurses, Inc. Certificate of Liability Insurance (3)DocuSign Envelope ID: 02A44B9B-80B2-4869-BE1C-985976DD286E AMER103 D 06/04/2020TE ) 06/04/2020 .qt vxu CERTIFICATE OF LIABILITY INSURANCE 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 endorsements . PRODUCER 626-914-9944 C NTACT Lori A. Patterson Jackson & Jackson Insurance 302 E Foothill Blvd San Dimas, CA 91773 PHONE 626-914-9944 FAX 626-914-1040 (A/C, No, Ext): A/C, No): E-MAIL . lori@jjinsurance.com ADDRESS INSURER(S) AFFORDING COVERAGE NAIC N INSURER A:James River Insurance Company 12203 INSURED American Forensic Nurses Inc., INSURER B : State Compensation Ins. Fund 35076 P.O. Box 1625 La Quintal, CA 92253 INSURERC: INSURER D : INSURER E : INSURER F : C_OVFRAGFS CERTIFICATE NUMRFR! REVISION NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY E P LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X X 00063557-5 08/21/2019 08/21/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC JECT OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG $ 3,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUE� pW TOS ONLY X AUTO ONLY X X 00063557-5 08/21/2019 08/21/2020 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PROPERTY AMAGE Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR EACH OCCURRENCE HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ B AND EMPLO WRKERS COMPENSATION ERS' L ABILIITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A X 9225103-2020 01/31/2020 01/31/2021 X PERLITE OTH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ A Professional Liab Retro 11/30/2004 00063557-5 08/21/2019 08/21/2020 Ea Claim Aggregate 1,000,000 3,000,000 � cMeniTeol Police bepa°i[ment; onensicCenricesaltliliaeRl.IN OTM ulegea@ be.c ched If more space Is required) its officers, officials, employees, agents and authorized volunteers are included as additional insureds, with regard to general liability, professional liability and auto liability of the named insured, per attached form AP2009US O4-10. Waiver of subrogation included per form (over) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Menifee THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 29844 Haun Road Menifee, CA 92586 AUTHORIZED REPRESENTATIVE ti.,---.— ACORD 25 (2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocW DocuSign Envelope ID: 02A44B9B-80B2-4869-BE1C-985976DD286E American Forensic Nurses, Inc. Policy #00063557-5 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 Additional 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 Additional 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 O410 Page 1 of 1 DocuSign Envelope ID: 02A44B9B-80B2-4869-BE1C-985976DD286E American Forensic Nurses, Inc. Policy #00063557-5 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 DocuSign Envelope ID: 02A44B9B-80B2-4869-BE1C-985976DD286E American Forensic Nurses, Inc. Policy #00063557-5 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 Name Of Additional Insured Person(s) Or Or anization s : If no entry appears above, this endorsement applies to all Additional Insureds covered under this PollcY. 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 specifically 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 DocuSign Envelope ID: 02A44B9B-80B2-4869-BE1C-985976DD286E ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 31, 2020 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JANUARY 31, 2021 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME AMERICAN FORENSIC NURSES, INC PO BOX 1625 LA QUINTA, CA 92247 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. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER BLANKET WAIVER OF SUBROGATION 9225103-20 RENEWAL SC 6-25-88-39 PAGE 1 OF NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SA�/JNNFRANCISCO: JANUARY 9, 2020 (/mot, AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.4-2018) 1 2572 OLD DP 217