|
Francine R. Digitally signed by Francine
<br />n. Villareal
<br />Villareal Dacer2lli 16:m:11
<br />A� �® CERTIFICATE OF LIABILITY INSURANCE
<br />DA 12021 YYYY
<br />osrzslzozl
<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 lieu of such endorsement(s).
<br />PRODUCER
<br />Marsh USA Inc.
<br />701 Market Street, Suite 1100
<br />St. Louis, MO 63101
<br />CONTACT Marsh I U.S. Operations
<br />PHONEAt 866-966A664 ac No)'
<br />E-MAIL ADDRESSAttq
<br />: CertRe uest marsh.com
<br />INSURERS AFFORDING COVERAGE
<br />NAIC#
<br />INSURER A: OM Republic Insurance Company
<br />24147
<br />CN103150778-GAW-CRT-21-22 N V kvl66g Y
<br />INSURED Wireless
<br />New Cingular reless PCS, LLC
<br />INSURER B:
<br />INSURER C
<br />One AT&T Plaza
<br />208 South Aland
<br />Room 1820
<br />INSURER D
<br />INSURER E
<br />Dallas, TX 75202
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: CHI-009523130-09 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.
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADOLSUBR
<br />Me
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMIDDIYYYY1
<br />POLICY EXP
<br />(IMMUDI)ADY'ryi
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE � OCCUR
<br />MWZY 31363621
<br />D610112021
<br />06/0112022
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />DAMAGES( RENTED
<br />PREMISES Ea occurrence)
<br />$ 1,000,000
<br />MED EXP Any one person)
<br />$ N/A
<br />PERSONAL B ADV INJURY
<br />$ 2,000,000
<br />GENT AGGREGATE LIMIT APPLIES PER:
<br />X POLICY 0 PEA LOC
<br />GENERALAGGREGATE
<br />$ 10,000,000
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />MWfB 31363521
<br />06/0112021
<br />0610112022
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 1,000,000
<br />X
<br />BODILY INJURY tPer parson)
<br />$
<br />A1NY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />JURY Per accitlent
<br />( ) BODILY IN
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTYDAMAGE
<br />Per accident
<br />$
<br />UMBRELLALIAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LIMB
<br />CLAIM' -MADE
<br />DEO I I RETENTION$
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANYPROPRIETORIPARTNERIEXECUrI /E
<br />OFFICERIMEMBEREXCLUDED?
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />MWC 313638 21 (ADS)
<br />061011 1
<br />001/2022
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />A
<br />Excess Workers' Compensation I
<br />MWXS 313639 21 (OH,WA)
<br />06101/2021
<br />05101/2022
<br />EL Each Accident I EL Disease
<br />1,000,000
<br />Employers' Liability
<br />See Second Page
<br />EL Disease -Policy Limit
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 1e1, Additional Remarks Schedule, may be attached If more space is required)
<br />Re: City of Santa Ana Municipal Facilities License Agreement.
<br />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
<br />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
<br />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
<br />policy terms, exclusions, and conditions.
<br />CERTIFICATE HOLDER
<br />City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />Risk Management Division THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />20 Civic Center Plaza ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Santa Ana, CA 92702
<br />of Marsh USA Inc. X
<br />APPR4 8DSrl REVIEwEDbAPPRav®BY:
<br />© 1988-2016 ACORD C #�" f,,r R. �I((A_�/_
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Risk Management Anayst
<br />
|