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A o CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DDNYYY)
<br />06/14/2012
<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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A 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 />CONTACT
<br />NAME:
<br />PHONE (206) 749-4800 FAX (206) 749-4860
<br />(A/C. No. Ext): A/C. No.):
<br />E-MAIL
<br />ADDRESS:
<br />1420 Fifth Avenue
<br />Suite 1200
<br />Seattle WA 98101-4030 USA
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC 1t
<br />INSURED
<br />INSURER A: XL Specialty Insurance CO
<br />37885
<br />T-Mobile USA, Inc
<br />its Subsidiaries and Affiliates
<br />INSURERB: Greenwich Insurance Company
<br />22322
<br />INSURERC: National Union Fire Ins Co of Pittsburgh
<br />19445
<br />12920 SE 38th Street
<br />Bellevue WA 98006 USA
<br />INSURER D:
<br />INSURER E:
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: b/UU4bb4b913 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. Limits shown are as requested
<br />LTR
<br />TYPE OF INSURANCE
<br />INSR
<br />WVD
<br />POLICY NUMBER
<br />MM/DD
<br />MMIDD
<br />LIMITS
<br />B
<br />GENERAL LIABILITY
<br />RGD
<br />EACH OCCURRENCE
<br />$1, 000, 000
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE x1 OCCUR
<br />PR AGE TO RENTED ES Ea occurrence)$1,
<br />000, 000
<br />MED EXP (Any one person)
<br />S5,000
<br />PERSONAL &ADV INJURY
<br />$1,000,000
<br />GENERAL AGGREGATE
<br />$2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP AGG
<br />$2 , 000 , 000
<br />POLICY PRO X LOC
<br />IECT
<br />B
<br />AUTOMOBILE LIABILITY
<br />RAD 500025701
<br />AOS
<br />05 01 2012
<br />05/01/2013
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$2,000,000
<br />BODILY INJURY ( Per person)
<br />B
<br />X ANY AUTO
<br />RAD 500025801
<br />05/01/2012
<br />05/01/2013
<br />ALL OWNED r SCHEDULED
<br />AUTOS AUTOS
<br />HIRED AUTOS NON -OWNED
<br />AUTOS
<br />MA
<br />BODILY INJURY (Per accident)
<br />PROPERTY DAMAGE
<br />Per accident
<br />C
<br />X
<br />UMBRELLA LIAB
<br />OCCUR
<br />13273159
<br />05/01/2012
<br />05/01/2013
<br />EACH OCCURRENCE
<br />$5,000,000
<br />EXCESS LIAB
<br />H
<br />CLAIMS -MADE
<br />SIR applies per policy terns
<br />& conditions
<br />AGGREGATE
<br />S5,000,000
<br />DED I X RETENTION
<br />A
<br />A
<br />WORKERS COMPENSATION AND
<br />EMPLOYERS' LIABILITY Y / N
<br />ANV PROPRIETOR I PARTNER / EXECUTIVE
<br />OFFICER/MEMBEREXCLUDED?
<br />N/A
<br />RWD5000301
<br />AOS
<br />RWR5000302
<br />05/01/2012
<br />05/01/2012
<br />05/Ol/2013
<br />05/01/2013
<br />X I WC STATU- I OTH-
<br />TORY LIMITS ER
<br />E.L. EACH ACCIDENT
<br />$1, 000 , 000
<br />E.L. DISEASE -EA EMPLOYEE
<br />$1, 000, 000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />yll
<br />E.L. DISEASE -POLICY LIMIT
<br />S1,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />The Certificate Holder and other entities as defined if required by written contract" are Additional Insured for General
<br />Liability and Automobile Liability solely as respect to operations of the Named Insured at the above location if required by
<br />contract. A waiver of Subrogation is granted in favor of Certificate Holder as required by written contract but limited to the
<br />operations of the Insured under said contract, with respect to the General Liability and Automobile Liability policy. General
<br />Liability and Automobile Liability evidenced herein is Primary and Non -Contributory to other insurance available to the
<br />Certificate Holder, but only to the extent required by written contract with the insured. Per Cancellation Notification to
<br />others Endorsement - In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium,
<br />CERTIFICATE HOLDER
<br />CANCELLATION
<br />.,!
<br />/
<br />J
<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 />, . _
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana City Fire Department. -
<br />Santa Ana CA 92707 USA
<br />F 'X' XM ylfitliw X"XI
<br />©1988-2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
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