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HomeMy WebLinkAboutNEW CINGULAR WIRELESS PCS, LLC (11)INSURANCE ON FILE A-2020-117J WORK MAY PROCEED UNTIL INSURANCE EXPIRES �G•al • CLERK OF COUNCIL Q % SUPPLEMENT AGREEMENT DA[T�E,:� c �J6"Le db�)(301A � ibis Supplement ("Supplement"), is approved by Licensor this ( IS day of gr-cl, , 20'Z:L (the date executed by all parties, referred herein as "Supplement Effective Date"). e 1. Supplement. Licensee has submitted an application for approval to use a Municipal sw Facility pursuant to that certain Municipal Facility License Agreement between Licensor and -41 Licensee dated July 8, 2020 "Agreement"). Licensor has reviewed the application and grants 9%? approval subject to the terms of this Supplement. All of the terms and conditions of the Agreement W are incorporated hereby by reference and made a part hereof without the necessity of repeating or attaching the Agreement. In the event of a contradiction, modification or inconsistency between the terms of the Agreement and this Supplement, the terms of this Supplement shall govern. Capitalized terms used in this Supplement shall have the same meaning described for them in the Agreement unless otherwise indicated herein. IF THE SUPPLEMENT IS NOT COUNTER- SIGNED BY LICENSEE AND RETURNED TO LICENSOR WITHIN 30 DAYS AFTER LICENSOR HAS GRANTED APPROVAL, THE SUPPLEMENT SHALL BE VOID AND OF NO LEGAL EFFECT. IF LICENSEE STILL WANTS TO USE THE MUNICIPAL FACILITY, LICENSEE WILL BE REQUIRED TO SUBMIT A NEW APPLICATION AND ASSOCIATED FEES. 2. Licensed Area Description and Location. Licensee shall have the right to use the space on the specific Municipal Facility (the "Licensed Area") depicted in Attachment I attached hereto to install Equipment as further listed in Attachment 2 attached hereto. 3. Equipment. The Equipment to be installed at the Licensed Area is described and depicted in Attachment 1. 4. Term. The term of this Supplement shall commence on the Supplement Effective Date and continue for the life of the Agreement, as described in Paragraph 2 of the Agreement. 5. License Fee/Alternate License Fee. The initial fee for this Supplement shall be as follows per year: $270.00. This fee is subject to annual increase as provided in the Agreement, and is payable in accordance with the Agreement. 6. Performance Bond. The Performance Bond [circle on is / snot covered by existing performance bond. If not covered by existing performance bond, a bond is required pursuant to Section 8 of the Agreement. Miscellaneous. [Signature page follows] FEW A-2020-117J IN WITNESS THEREOF, the parties hereto have caused this Supplement to be legally executed in duplicate, effective upon execution by both parties. Licensor: CITY OF SANTA ANA, CA By: 4 --j \YC, /i w Name: Nabil Saba, P.E. Title: Executive Director Public Works Agency Date: 03/07/2022 Licensee Accepted: �Ve.r �J -far W ; neless PC S LL C ►bs AT4T fAabl Wi -y By:_ a f Name: 6MAR,l�IcFL Title: PPIcA Iy\A� Date: Attachments: Attachment 1 — Licensed Area (STANA_Node _005) Attachment 2 — Equipment List and Description FEW Attachment 1 Licensed Area [Map showing licensed area of applicable Municipal Facility and showing proposed Equipment installation A-3 a� b U -� e S B m e m z� _ • i' � I it _ -__ �s rad�aaasa+s o � S • - - 15 tlVla[:rla m -- —i • • and oiu�da s 3r. vilovas • I I • 1 � I tJ j o I ATTACHMENT 1 CONTINUED J r- ATT GAATMT)k NU EYt.TN. ANTENNA ATT RRU S INSIDE SIiROUDS NEW REPLACE:WNT UGHT POLE RELOCATED SIGNAGE NEW PULL BOXES ALONG EXISTING LANDSCAPE AREA I FEW ATTACHMENT 2 Equipment List: Antenna: GQ2414-B6770 Antenna mount and radio shroud: Ill S CUMMMRf CfSI F (NJ UINI 41R A! 6 Si�iOx; P0.E alwta M k r(T) wus-.«A (zJ I1) ML5-1�11 (1) P611 4O CU;[S1.J13rt ={j- e5"lfio4 I CfMG/dytwl SYAOUII &flOIO � OVrlln, Twnp.nW ACu HFf MPb�JPCI • wlM 305 vn IJ..P mna NdEE{ MS'6JT.�ed uibn. Wv:.l .W minr 4n wr.lie fr (m rC�b mpeafne¢IM OwmortK51 Wndlu�riwl4uw 150mMlyt {uN (1) KKU4415 S itFai_'.) (1) RRL14449 W ((pp �4IflE Ik}IT SIECIUWT - IM1 FSef59D� WUnI -tir' d• k4J m�rruuF_�I - s-now 4aMTm n* T¢i a va= E, EvA-noN (i.l' TM 5[ s) Equipment Shroud: (1) at each side (2-total) 14.6" 28.0" 1d.6T' SPD: (1) RSCAC-1333-PH-240 /4 RSCAC-1333-PH-240 wi Francine R. Digitally signed by Francine n. Villareal Villareal Dacer2lli 16:m:11 A� �® CERTIFICATE OF LIABILITY INSURANCE DA 12021 YYYY osrzslzozl THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh USA Inc. 701 Market Street, Suite 1100 St. Louis, MO 63101 CONTACT Marsh I U.S. Operations PHONEAt 866-966A664 ac No)' E-MAIL ADDRESSAttq : CertRe uest marsh.com INSURERS AFFORDING COVERAGE NAIC# INSURER A: OM Republic Insurance Company 24147 CN103150778-GAW-CRT-21-22 N V kvl66g Y INSURED Wireless New Cingular reless PCS, LLC INSURER B: INSURER C One AT&T Plaza 208 South Aland Room 1820 INSURER D INSURER E Dallas, TX 75202 INSURER F : COVERAGES CERTIFICATE NUMBER: CHI-009523130-09 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADOLSUBR Me POLICYNUMBER POLICY EFF MMIDDIYYYY1 POLICY EXP (IMMUDI)ADY'ryi LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR MWZY 31363621 D610112021 06/0112022 EACH OCCURRENCE $ 2,000,000 DAMAGES( RENTED PREMISES Ea occurrence) $ 1,000,000 MED EXP Any one person) $ N/A PERSONAL B ADV INJURY $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY 0 PEA LOC GENERALAGGREGATE $ 10,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: A AUTOMOBILE LIABILITY MWfB 31363521 06/0112021 0610112022 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X BODILY INJURY tPer parson) $ A1NY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS JURY Per accitlent ( ) BODILY IN $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIMB CLAIM' -MADE DEO I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNERIEXECUrI /E OFFICERIMEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA MWC 313638 21 (ADS) 061011 1 001/2022 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Excess Workers' Compensation I MWXS 313639 21 (OH,WA) 06101/2021 05101/2022 EL Each Accident I EL Disease 1,000,000 Employers' Liability See Second Page EL Disease -Policy Limit 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 1e1, Additional Remarks Schedule, may be attached If more space is required) Re: City of Santa Ana Municipal Facilities License Agreement. The City of Santa Ana, its officers, officials, employees and volunteers islam included as Additional Insured under the General Liability policy but only wild respect to the requirements of the contract between the Certificate Holder and the Insured. Waiver of Subrogation is provided for General Liability, as required by written contract and allowable by law. This insurance is primary with respect to the interest ofthe Additional Insured and any other insurance maintained by Additional Insured is excess and noncontributory with this insurance. Contractual Liability under the General Liability but only to the extent dictated by policy terms, exclusions, and conditions. CERTIFICATE HOLDER City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Risk Management Division THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 Civic Center Plaza ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana, CA 92702 of Marsh USA Inc. X APPR4 8DSrl REVIEwEDbAPPRav®BY: © 1988-2016 ACORD C #�" f,,r R. �I((A_�/_ ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Risk Management Anayst AGENCY CUSTOMER ID: CN103150778 _ LOC #: St. Louis A� ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. New Cingular Wireless PCS, LLC One AT&T Plaza 208 South Akard POLICY NUMBER Room 1820 Dallas, TX 75202 CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: LO FORM TITLE: Excess Workers' Compensation -MWXS 313639 21 (OH -WA) Sell Insured Retenfions OH & WA - $500.000,000 (except Tenonsm) OH & WA - $600,000,000 Terrorism t ^uwBnma armlet ' REtnEvum& APPRov® ar sT ACORD 101 (2008101) © 2008 ACORD C 9l . n F M-4r a Z Vj&'Al[ The ACORD name and logo are registered marks of ACORD I =�—ww' Rok Management Analyst POLICY NUMBER:MWZY 313636 21 COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations All Persons or Organizations as Required by Written The Locations as specified in the written contracts or Contract or Agreement. agreements. In no event shall the insurance provided exceed the scope of coverage or limits required by said contract or a reemmaetiont. Inforn re uired to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contractor agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its Intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project wakM�.gmntmM�n ,+% c fffi+nelvEn6 APPROVED Sr CG 20 10 12 19 © Insurance Services Office, Inc., 2018 Ruk Managem nl Mays[ MWZY 31363621 AT&T Inc. 0610112021-0610112022 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. Page 2 of 2 © Insurance Services Office, Inc., 2018 MWZY 31363621 AT&T Inc. 0610112021. 0610112022 RiskMu%miadDMsEnn Rentwm & ARRRQV® BY: ��, Risk Management Analyst POLICY NUMBER:MWZY 313636 21 COMMERCIAL GENERAL LIABILITY CG 20 37 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations All Persons or Organizations as Required by Written The Locations as specified in the written contracts or Contract or Agreement. agreements. In no event shall the insurance provided exceed the scope of coverage or limits required by said contract or Mnt. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contractor agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. H ftvi n & Aaatov® Or. i"u�vrin.e Z U:&n6ct' CG 20 37 12 19 C Insurance Services Office, Inc., 2018 �' Nuk Management Malyst MWZY 31363621 AT&T Inc. 06/01/2021-06101/2022 01 IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED AMENDMENT - PRIMARY AND NON-CONTRIBUTORY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM As respects any person(s) or organization(s) included as an additional insured and with whom you have agreed in a written contract, agreement or permit to provide primary insurance on a non-contributory basis, this insurance will be primary to and non-contributing with any other insurance available to such person(s) or organization(s). In no event shall the insurance provided exceed the scope of coverage or limits required by said contract or agreement. REM=Wde Mum},mnmi. Dtvielmt APPRava)Br. - GL 739 042 0612 ®% f , t jam, V&c"j Risk Management Analyst MWZY 31363621 AT&T Inc. 06/01/2021-0610112022 IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS This endorsement modifies the notice of cancellation of insurance provided hereunder by adding the following: A. In the event this policy is cancelled for any permissible reason, other than for nonpayment of premium, we shall endeavor to provide advance written notice of cancellation to certificate holders set out in the schedule on file with the Company, after notifying the first Named Insured of such cancellation. Notice of cancellation to certificate holders may be made by any commercially reasonable means, including mail, electronic mail, facsimile transmission or courier service. B. This advance written notification of a cancellation of coverage is intended as a courtesy only. Our failure to provide such advance written notification will not extend the policy cancellation date, nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. Risk ,9 oryg„w.any�o o, REVIevsoED ApmovtD Eh: Foe.eee V&AVAl PIL 02910 10 Risk Management Maryst MWTa 31363521 AT&T Inc. 06/01/2021 -06101 P2022 IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS This endorsement modifies the notice of cancellation of insurance provided hereunder by adding the following: A. In the event this policy is cancelled for any permissible reason, other than for nonpayment of premium, we shalt endeavor to provide advance written notice of cancellation to certificate holders set out in the schedule on file with the Company, after notifying the first Named Insured of such cancellation. Notice of cancellation to certificate holders may be made by any commercially reasonable means, including mail, electronic mail, facsimile transmission or courier service. B. This advance written notification of a cancellation of coverage is intended as a courtesy only. Our failure to provide such advance written notification will not extend the policy cancellation date, nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. RiskMWV9an0dDMdm �`������RtnEwEn s Mrnwm BY: Pll 029 10 10 F'lM' .r.e P. Vau'"t ® Risk Manager nt Analyst MWZY 31363621 AT&T Inc. 06/01/2021-06/0112022 Of OLD REPUBLIC INSURANCE COMPANY WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY NOTICE OF CANCELATION TO CERTIFICATE HOLDERS ENDORSEMENT This endorsement modifies the notice of cancelation of insurance provided hereunder by adding the following: A. In the event this policy is canceled for any permissible reason, other than for nonpayment of premium, we shall endeavor to provide advance written notice of cancelation to certificate holders set out in the schedule on file with the Company, after notifying the Insured first named in item 1 of the Information Page of such cancelation. Notice of cancelation to certificate holders may be made by any commercially reasonable means, including mail, electronic mail, facsimile transmission or courier service. B. This advance written notification of a cancelation of coverage is intended as a courtesy only. Our failure to provide such advance written notification will not extend the policy cancelation date, nor negate cancelation of the policy. All other terms and conditions of this policy remain unchanged. WC 99 03 64 (03/ 11) Page 1 of 1 Rink MergementDMston REVIEWED 6 APPRovm Sr. ® Ruk Managemen[Malyst