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HKLJ CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DD/YYYY)
<br />11/16/2010
<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 DOErRiOfrN$TITUTe AgC:CI RACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE 1 J
<br />IMPORTANT: If the certificate holder is an ADDITIONAL (NSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the
<br />terms and conditions of the policy, certain policie jn�y.'require an endorsen5eht''�k statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />Aon Risk insurance Services West, Inc.
<br />Seattle wA Office
<br />1420 Fifth Avenue
<br />suite 1200
<br />CONTAC'c
<br />NAME:
<br />PHONE
<br />(AIC. No. Ext): (206) 749 -4800 FAX No : (206) 749 -4860
<br />EMAIL
<br />Seattle WA 98101 -4030 USA
<br />PROCER 10616550
<br />CUSTODUMER ID M
<br />INSURED
<br />T- Mobile USA, Inc.
<br />its Subsidiaries and Affiliates
<br />INSURER(S) AFFORDING COVERAGE
<br />INSURER A: Fidelity & Guaranty Ins Co
<br />NAIC #
<br />35386
<br />INSURER B: National Union Fire Ins CO Of Pittsburgh
<br />19445
<br />12920 SE 38th Street
<br />Bellevue wA 98006 USA
<br />INSURER c: Discover Property & Casualty Ins Co
<br />36463
<br />INSURER D: Fidelity &Guaranty Ins u/w
<br />25879
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<br />INSURER E: United States Fidelity & Guaranty Co.
<br />25887
<br />COVERAGES CFRTIFIrATC NIIIU12CO. r7nnnn0o11co
<br />INSURER F:
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<br />r�G V lJlwry Ru1n1oC11%:
<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 />Limits shown are as requested
<br />fR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY MM/DD LIMITS
<br />GENERAL LIABILITY GL 057nT= d5/01/2011 *EACHOCCU RENCE $1,000,000
<br />X COMMERCIAL G ENERAL LIABILITY $1,000,000
<br />[ 77 n a occurrence CLAIMS -MADE ❑X OCCUR .1 A� dt y one person) $25 , 000
<br />X Contractual Liability Incl. , ADV INJURY $ co
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />POLICY PRO- X LOC
<br />B AUTOMOBILE LIABILITY
<br />B X ANY AUTO
<br />ALL OWNED AUTOS
<br />SCHEDULED AUTOS
<br />HIRED AUTOS
<br />NON OWNED AUTOS
<br />UMBRELLA LIAR [I OCCUR
<br />EXCESS LIAB CLAIMS -MADE
<br />DEDUCTIBLE
<br />RETENTION
<br />A
<br />EMPLOYERS' LIABILITY
<br />E ANY PROPRIETOR / PARTNER / EXECUTIVE
<br />OFFICERIMEMBER EXCLUDED?
<br />(Mandatory In NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />AOS
<br />CA 9835799 05/01/2010
<br />SIR applies per policy terns & condi {ions
<br />N /AI ID003WO0409 10
<br />E.L. EACH ACCIDENT $1,000,000
<br />E.L. DISEASE -EA EMPLOYEE $1, 000 000
<br />E.L. DISEASE - POLICY LIMIT 41 nnn nnn
<br />DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more apace Is required)
<br />Site Number: LA33835A site Name: Adams Park, Site Address: 2302 S. Raitt street, Santa Ana, CA 92704. The Certificate
<br />Holder is an Additional Insured for General Liability solely as respect to operations of the Named Insured at the above
<br />location if required by contract.
<br />CERTIFICATE HOLDER
<br />1,000,000
<br />GENERAL AGGREGATE
<br />$2,000,000
<br />r
<br />i�
<br />PRODUCTS - COMP /OP AG G
<br />$2,000,000
<br />POLICY PROVISIONS.
<br />0
<br />0
<br />u^i
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$2,000,000
<br />BODILY INJURY ( Per person)
<br />o
<br />BODILY INJURY (Per accident)
<br />4)
<br />Po Box 1988
<br />Santa Ana CA 92702 USA
<br />d
<br />PROPERTY DAMAGE
<br />ip
<br />Per accident
<br />V
<br />w
<br />d
<br />U
<br />EACH OCCURRENCE
<br />$5,000,000
<br />AGGREGATE
<br />$5,000,000
<br />E.L. EACH ACCIDENT $1,000,000
<br />E.L. DISEASE -EA EMPLOYEE $1, 000 000
<br />E.L. DISEASE - POLICY LIMIT 41 nnn nnn
<br />DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more apace Is required)
<br />Site Number: LA33835A site Name: Adams Park, Site Address: 2302 S. Raitt street, Santa Ana, CA 92704. The Certificate
<br />Holder is an Additional Insured for General Liability solely as respect to operations of the Named Insured at the above
<br />location if required by contract.
<br />CERTIFICATE HOLDER
<br />CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
<br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
<br />POLICY PROVISIONS.
<br />City of Santa And
<br />Attn: Clerk of the Council
<br />AUTHORIZED REPRESENTATIVE
<br />20 civic Center Plaza (M -30)
<br />Po Box 1988
<br />Santa Ana CA 92702 USA
<br />9b
<br />e�'a �Fu
<br />ACORD 25 2009/09 ©1988 -2009 ACORD CORPORATION. All rights reserved.
<br />( ) The ACORD name and logo are registered marks of ACORD
<br />
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