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ACORD® CERTIFICATE OF LIABILITY INSURANCE <br />111 5/1/2018 <br />DATE(MMIDONYYYI <br />9/7/2017 <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(les) 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 Hart of such endorsement(s). <br />PRODUCER LOckton Companies <br />Three City Place Drive, Suite 900 <br />St. Louis MO 63141-7081 <br />(314) 432-0500 <br />CONTACT <br />PHONE FAX <br />E AIC No <br />E-MAIL <br />ADDRESS: <br />'�. COMMERCIAL GENERRAAL LIABILITY <br />Y I N <br />RGD5000259-06 <br />INSURERS AFFORDING COVERAGE <br />MAIC# <br />INSURER A: XL Insurance America Inc. <br />24554 <br />INSURED T -Mobile US, Inc. <br />1359691 Its Subsidiaries and Affiliates <br />INSURER B: Greenwich Insurance Company <br />22322 <br />INSURER C: National Union Fire Ins Co Pitts. PA <br />19445 <br />12920 SE 38th Street <br />Bellevue WA 98006 <br />INSURER D: <br />MED EXP (Any one person) $ 5,000 <br />INSURER E: <br />INSURER F: <br />COVERAGES TMOBI CERTIFICATE NUMBER: 14936216 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 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 <br />LTR <br />TYPE OF INSURANCE <br />ADDL.SUBR <br />POLICY NUMBER <br />j POLICY EFF <br />, MMIDDn <br />POLICY EXP <br />MMIDDNYYV <br />LIMITS <br />B <br />X <br />'�. COMMERCIAL GENERRAAL LIABILITY <br />Y I N <br />RGD5000259-06 <br />5/1/2017 <br />5/1/2018 <br />EACH OCCURRENCETo $ 1,000,000 <br />PREMISES (Ea occurrence $ 1,000,000 <br />CLAIMS-MADE$'.00CUR <br />MED EXP (Any one person) $ 5,000 <br />PERSONAL &ADV INJURY $ 1,000,000 <br />AGGREGATE LIMIT APPLI ES PER: <br />GENERAL AGGREGATE $ 2000000 <br />GEN'L <br />POLICY [:]JECT ❑X LOC <br />PRODUCTS - COMP/OP AGO $ 2,000,000 <br />$ <br />OTHER: <br />B <br />AUTOMOBILE <br />LIABILITY <br />N N <br />RAD5000257-06 <br />5/1/2017 <br />5/1/2018 <br />E MSINEDdentSINGLE LIMIT $ 2 000 000 <br />BODILY INJURY (Per person) $ XXXXXXX <br />ANY AUTO <br />I <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />BODILY INJURY Per accident $ <br />( ) xxxxxXX <br />_ <br />`. PROPERTY DAMAGE $ XXXXXXX <br />LPeraccitlent)__._ <br />i_ <br />$XXXXXXX <br />C <br />X <br />UMBRELLA LIAR <br />�' <br />OCCUR <br />N <br />N <br />28189156 <br />5/1/2017 <br />5/1/2018 <br />EACH OCCURRENCE $5000000 <br />C <br />C <br />excess uAB <br />CLAIMS -MADE <br />SIR applies per policy <br />terms &conditions <br />AGGREGATE $ 5,000,000 <br />DED X RETENTION$ 25,000 <br />_ <br />1 $ XXXXXXX <br />A <br />`4 <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOR/PARTNER/EXECUTIVE YIN <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />NIA <br />1�T <br />RWR5000301-05 AOS <br />RWR5000302-OS WI <br />5/1/2017 <br />5/1/2017 <br />5/1/201$ <br />�5/I/2018 <br />X STATUTE EORH___ <br />E.L_EACHACCIDENT $ 1,000,000 <br />E.L. DISEASE - EA EMPLOYEE $ 1,000,000 <br />If yyes, tleson a under <br />DESCRIPTIONOFOPERATIONSbelow <br />E. L. DISEASE -POLICY LIMIT $ 1,000.000 <br />�ate< <br />DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is mqulmd) <br />**SEE ATTACI-IED ENDORSEMENTS** RE: FIESTAS PATRIAS EVENT, CITY OF SANTA ANA IS ADDITIONAL INSURED ON A PRI' AND <br />NON-CONTRIBUTORY BASIS UNDER GENERAL LIABILITY AS REQUIRED BY WRITTEN CONTRACT. ck �J <br />CERTIFICATE HOLDER CANCELLATION See Attachments Y ' <br />14936216 <br />CITY OF SANTA ANA <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />AT•IN: SONIA BATRES <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 CIVIC CENTER PLAZA PO BOX 1988 <br />SANTA ANA CA 92702 <br />AUTHORIZED REPRESENTATI <br />r <br />ACORD 25 (2016103) <br />©1988.2rri ACORD CORPORATISM. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />