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,AIC"Rit7GERTIF'IGATE �3F LIABILITY INSURANCE <br />....- ' 511/2017 <br />FDATEIMwDDIYYYY) <br />9!8/2016 <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 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 Lockton Companies <br />Three City Place Drive, Suite 900PHONE <br />St. Louis MO 63141-7081 <br />(314) 432-0500 <br />CONTACT <br />NAME: <br />FAX <br />AIC, No, Extl: A/C,No <br />E-MAIL <br />ADDRESS: <br />INSURERS AFFORDiNG COVERA 'E NAIC p <br />INSURERA: XL Insurance America. Inc. 24554 <br />INSURED T -Mobile US, Inc. <br />1359691 b SubSldlaries and Affiliates <br />12920 SE 38th Street � <br />Bellevue WA 98006 f' ,.., M 4 .. � �`al <br />INSURER 13: GiVel7W1Ch I11SUranCeCompany 22322 <br />INSURER C : National Union Fire his Co Pitts PA 1944'5 <br />INSURER D <br />INSURER E. <br />INSURER F <br />COVERAGES TMOBI CERTIFICATE NUMBER: 14249849 REVISION NUMBER: XXXXXXX <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 THUS <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 <br />LTR <br />TYPE OF INSURANCE <br />ADEL <br />INSD <br />SUER <br />WVD <br />POLICY NUMBER. <br />POLICY EFF <br />'MMIDDIYYYY <br />POLICY EXP <br />MMIDDIYYYY <br />LIMITS <br />H <br />X COMMERCIAL GENERALLIABILITY <br />N <br />N <br />RGD5000259-05 <br />5/1/2016 <br />511/2017 <br />EACH.. OCCURRENCE S 1000000 <br />CLAIMS -MADE OCCUR <br />PREMISES©RENTED <br />cnce S 1000 000 <br />MED EXP (Any oneperson) S 5.000 <br />PERSONAL S ADV INJURY S 1000,000 <br />PGEN'L AGGREGATE LIMIT APPLIES PER. <br />POLICYPf-ClRO- O LPC <br />GENERAL AGGREGATE S 2 000 000 <br />PRODUCTS -COMPIOP AGG5 2,000000 <br />5 <br />OTHER: <br />13 <br />AUTOMOBILE <br />LIABILITY <br />N <br />N <br />IZAD5000257-05 <br />511/20,16 <br />51112017 <br />EOa RRINEDISINGLE LIMIT $ 2cc,den' <br />-_20001000 <br />BODILY INJURY (Per person) S XXXXXXX <br />X <br />ANY AUTO <br />OWNAAUTOS ONLY SCHEDULED <br />INJURY (Per accddmt $ XXXXXXX <br />HIRED NON -OWNED <br />AUTO'S ONLY AUTOS ONLY <br />PROPERTY CAMAGC. <br />Per accident) $ XX.XXX.XX <br />C <br />X. <br />UMBRELLA LIAB <br />X <br />OCCUR <br />N <br />N <br />19086894 <br />5/1/2016 <br />511/2(117 <br />EACH OCCURRENCE $ 5,000,000 <br />C <br />C <br />EXCESS LIAB <br />CLAtlMS-MADE <br />SIR, pplies per policy <br />terms c� Conditions' <br />AGGREGATE <br />DED I X.. I RETENTIONS 25„000 <br />_$5,000,000 <br />$XXXXX.XX <br />A <br />A <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETORIPARTNERIEXECUTIVE�f <br />DFFICFR,MEMBER EXCLUDED? A V <br />(Mandatary in NN) <br />if yes, de ',be enderIt <br />DESCRIPTION OF OPERATIONS below <br />NIA <br />N <br />RWD5000301-04 AOS <br />RWR5000302-04 WI <br />51'1/2016 <br />5/1/2016 <br />51112017 <br />5/112017 <br />PER OTH- <br />X STATUTE ER <br />E AQ <br />-L EH ACCIDENT g 1,000,000 <br />E.L INSEASE . EA EMPLOYEE S 1,000,000 <br />EL.. MSEASE - POLICY LIMIT, 1,000,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 401, Additional Remarks Schedule, may be attached if more space is required) , <br />**SLI:ATTACHED I:N[)ORSI M1:N'I'S** RE SPECIAL LVEN'T'. THE CITY O1' :SANTA ANA, IT'S OFFICERS, LMPLOYEI:S � <br />RI PRI SI NIA'TIVI: ARI, AD171-1-I6NAL INSUREDS ON A PRIMARY AND NON-CONTRIBUTORY BASIS UNDI R ill: I � ILI`TY 11 D A' Imo, <br />ADDFTO AL RED UNDER <br />MOBILE LIABILITY AS R17QUIRED BY WRIT I`E;N CONTRACT WAIVER O ROG ;PJON L <br />IN1L LIABILITY ANDA <br />AUTOMOBILE LIABILITY AS REQUIRED BY WRI'17FN CONTRACT.� <br />CERTIFICATE HOLDER CANCELLATION See Attachments rNf� k T T " <br />14249849 <br />CITY OF SANTA ANA <br />SILVIA CUEVAS <br />20 CIVIC CENTER PLAZA M-23 <br />SANTA ANA CA 92701 <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 />REPRESENTATIVE <br />op <br />ACORD 26 (2016/03) @1988-2&";ACORD COTTFORATRSN. All rights reserved <br />The ACORD name and logo are registered marks of ACORD <br />J <br />