|
Page 1 of 2
<br />AIR& CERTIFICATE OF LIABILITY INSURANCE
<br />D03/28/2019
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ie8) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />Willis of Pennsylvania, Inc.
<br />c/o 26 Century Blvd
<br />P.O. Box 305191
<br />CONTACT
<br />NAME:
<br />A/C No E#: 1-877-945-7378 aC No: 1-888-467-2378
<br />EMAIL
<br />E-MAILADDRESS: certificatea@willia.com
<br />INSURER(S) AFFORDING COVERAGE NAIC#
<br />Nashville, TN 372305191 USA
<br />INSURERA: Federal Insurance Company 20291
<br />INSURED
<br />Crown Castle International
<br />See Attached Named Insured List �"W
<br />Insured List
<br />INSURER B: National Union Fire Insurance Company of P 19445
<br />Berkshire Hathaway Specialty Insurance Cost 22276
<br />INSURER C: y P y
<br />INSURER O: New Hampshire Insurance Company 23841
<br />1220 Augusta Dr. Suite 600
<br />Houston, TX 77057
<br />INSURER E
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: W10675400 REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR ADDL SUER POLICY EFF POLICY EXP
<br />LTR TYPE OF INSURANCE D POLICYNUMBER MMIL0,Y) MMIDOI rE
<br />LIMITS
<br />X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE $ 1,000,000
<br />CLAIMS -MADE %<. OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence) S 1,000,000
<br />A
<br />MED EXP(Any one person) $ 10,000
<br />y y 3605-3335 04/01/2019 04/01/2020
<br />PERSONAL a ADV INJURY $ 1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERALAGGREGATE S 2,000,000
<br />%< POLICY PRO-
<br />JECT',,LOC
<br />PRODUCTS - COMPIOPAGG $ 2,000,000
<br />OTHER
<br />$
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT $ 1,000,000
<br />Ea accident
<br />X ANY AUTO
<br />BODILY INJURY(Per person) $
<br />B OWNED SCHEDULED y y CA 4993143 04/01/2019 04/01/2020
<br />BODILY INJURY (Per accident) $
<br />_ AUTOS ONLY _ AUTOS
<br />HIRED NON -OWNED
<br />PROPERTY DAMAGE $
<br />AUTOS ONLY _ AUTOS ONLY
<br />_(Per Student
<br />C X UMBRELLA LIAB X OCCUR
<br />EACH OCCURRENCE $ 5,000,000
<br />EXCESS LIAB CLAIMS -MADE y y 47-UMO-303445-03 04/01/2019 04/01/2020
<br />AGGREGATE $ 5,000,000
<br />DED X RETENTION$ 25,000
<br />$
<br />WORKERS COMPENSATION
<br />X PER OTH-
<br />STATUTE ER
<br />AND EMPLOYERS' LIABILITY YIN
<br />D ANYPROPRIETORIPARTNER/EXECUTIVE
<br />No y
<br />E.L. EACHACCIDENT $ 1,000,000
<br />OFFICERIMEMBER EXCLUOE07 NIA WC 012717229 04/01/2019 04/01/2020
<br />(MandatorylnNH)
<br />— --- —-
<br />E.L. DISEASE - EA EMPLOYEE $ 1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />SEA.E- POLICY T $ 1, 000, 000
<br />4e
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mo ce is m4ir
<br />HU#828440 - TM3009 El Salvador Park, 1825 3/4 Civic Center Drive West Suite W, Santa
<br />City of Santa Ana, its officers, agents, representatives, employees and volunte
<br />rDXllstied as Additional Insureds
<br />-under -the-General -Liabi-li-ty, Auto-LiatrrH{y-andumbrelle/-Excess-Liability Pol' ie a - �...e-r-interest may -appear -and -as -
<br />required by written agreement and only with respect to the liability arisi out oi�
<br />e operations performed by or on
<br />behalf of the Named Insured.
<br />City of Santa Ana
<br />Parks, Recreation and Community Services Agency - M23
<br />20 Civic Center Plasa, 2nd Floor, RM #273
<br />P.O. Box 1988
<br />Santa Ana, CA 92702
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />© 1988-2016 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />SR ID: 17717460 rercR: 1129834
<br />
|