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CERTIFICATE OF LIABILITY INSURANCE
<br />OATE(MM/DDA'YYY)
<br />061,42D,2
<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 />cartificate holder In lieu of such endorsement(s).
<br />PRODUCER
<br />CONTACT
<br />ADO Risk Insurance Services West, Inc.
<br />Seattle WA Office
<br />PXNAMN
<br />(A'C.No.ExO:
<br />(206) 749-4800 FA% (206) 749-4860
<br />AK:. No.:
<br />ADDRESS:
<br />1420 Fifth Avenue
<br />Suite 1200
<br />INSURER(S) AFFORDING COVERAGE
<br />HAIG
<br />Seattle WA 98101-4030 USA
<br />INSURED
<br />T-Mobile USA, Inc
<br />its subsidiaries and Affiliates
<br />12920 SE 38th street
<br />INSURER A: XL Specialty Insurance cc
<br />37885
<br />INSURER B: Greenwich Insurance Company
<br />22322
<br />INSURER C: National union Fire Ins co of Pittsburgh
<br />19445
<br />INSURER D:
<br />Bellevue WA 98006 USA
<br />INSURER E: _
<br />INSURER F:
<br />v 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 />INSR L
<br />TYPE OF INSURANCE
<br />lWg
<br />yyyp
<br />POLICY NUMBER
<br />M 0 OLICY EFF
<br />I POLICY SKI,
<br />MAVD
<br />LIMITS
<br />GENERAL LIABILITY
<br />RGD
<br />EACHOCCURRENCE
<br />$1,000,000
<br />PREMISE Ea occurrence
<br />$1, 000, 000
<br />COMMERCIAL GENERAL LIABILITY
<br />NED EXP(Any one pemon)
<br />$5,000
<br />CLAIMS -MADE 0OCCUR
<br />PERSONAL &AM INJURY
<br />$1,000.000
<br />I
<br />GENERAL AGGREGATE
<br />$2,000.000
<br />GENL AGGREGATE
<br />LIMIT APPLIES
<br />PER:
<br />PRODUCTS-COMPIOP AGG
<br />$2, 000, ODO
<br />POLICY
<br />PRQ X
<br />LOC
<br />e
<br />AUTOMOBILE UA131LITY
<br />Fue 5000257 1
<br />ADS
<br />OS 01 0
<br />5 1 013
<br />COMBINED SINGLE LIMIT
<br />Me a dent
<br />$2.000,000
<br />B
<br />% ANY AUTO
<br />BAD 500025801
<br />05/01/2012
<br />OS/01/2013
<br />BODILY INJURY (Per pera.)
<br />BODILY INJURY (Per accident)
<br />DHEDDLD
<br />ALL OWNEDPHO"'N'll
<br />MA
<br />AUTOS UTOS
<br />HIREDAWOS
<br />AUTOS
<br />PROPERTY DAMAGE
<br />Per accident
<br />C
<br />X-
<br />UMBRELLAUAe
<br />EXCESS UAIS
<br />%
<br />OCCUR
<br />CLAIMS -MADE
<br />13273159
<br />sIR applies per policy terns
<br />OS 01 2012
<br />& COnd1
<br />05/0l 2013
<br />ions
<br />EACH OCCURRENCE
<br />$5,000,000
<br />AGGREGATE
<br />$5,000.000
<br />DED I %RETENTION
<br />A
<br />A
<br />WORKERS COMPENSATION AND
<br />EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR I PARTNER I EXECUTIVE Y/N
<br />OFFICERMEMBER EXCLUDED') N
<br />(Mandatory In NH)
<br />NIA
<br />RWD600 3O1
<br />ADS
<br />RWR$DDD3D2
<br />WI
<br />OS 012
<br />05/D1/2D12
<br />O$ 01 2 1ftE.L.DISEASE-EA
<br />D$/O1/2013
<br />Y LIMITS ORH
<br />IMIT
<br />ACCIOEN7
<br />$S, OOO,OOO
<br />EMPLOYEE
<br />$1,000,000
<br />Inndeecdne under
<br />DESCRIPTION OF OPERATIONS below
<br />A SE -POLICY LIMIT
<br />$1, 000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Anach ACORD 101, Additional Remarks Schedule, ff more spec. b reealred)
<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 />1.3' I'.iCtJ y 1'„1 : ',' i (i ; ., CANCELLATION
<br />CERTIFICATE HOLDER .. ,.
<br />ULD ANY OF THE
<br />OVE DESCRIBED POLCIES 80 CANCELLED BEFORE THE
<br />.. .:;�L..i/.a'UKX (� 1 A / / / �% I POIIRATION ITE THEREOF, , NOTICE WILL BE DEILIVERED IN ACCORDANCE WITH THE
<br />City Of Santa And ._IIUi:. „( 1,.,..,�(Iy AUTHORIZED REPRESENTATIVE
<br />Santa Ana Cityy Fire DepaRtlryeht
<br />Santa Ana CA 92707 USA Wa ✓f✓1"w yFwmie WMA
<br />01988-22070 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
<br />
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