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Francine R. 119isllysi0ned by Franrine
<br />R. Villareal
<br />Villareal Date: 102101.01 M47:11
<br />,ACi CERTIFICATE OF LIABILITY INSURANCE
<br />1i
<br />DAT€ /2021 nvyY)
<br />061262021
<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 Markel Street, Suite 1100
<br />St. Louts, MO 63101
<br />CONTACT Marsh I U.S. Operations
<br />PHONE 866-966-4664 file No
<br />A MOAILSS AIt.CedRequest@marsh.com
<br />INSURERS AFFORDING COVERAGE
<br />NAICN
<br />CN103150778-GAW-CRT-21-22 N Y kv165g Y
<br />INSURER A: Old Republic Insurance Company
<br />24147
<br />INSURED
<br />New Cingular Wireless PCS, LLC
<br />INSURER B :
<br />INSURER C :
<br />One AT&T Plaza
<br />208 South Akard
<br />INSURER D :
<br />Room 1820
<br />INSURER E :
<br />Dallas, TX 75202
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: CHb009523130-09 RPVIRInN NIIMPUP17-
<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 />ILTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />Wen
<br />BDBR
<br />vomn
<br />POLICYNUMBER
<br />POLICY EFF
<br />MWDDIYYYV
<br />POLICY EXP
<br />MMIDWYYYYI
<br />LIMITS
<br />A
<br />GENERAL LIABILITY
<br />MWZY 31363621
<br />06101I2021
<br />06101/2022
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />4COMMERCIAL
<br />DA AG TOKEN ED
<br />CLAIMS-MADEI-XI OCCUR
<br />PREMISES Eaoccurrencen
<br />$ 1,000,000
<br />MED EXP (Any one person)
<br />$ NIA
<br />PERSONAL &ADV INJURY
<br />$ z,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERALAGGREGATE
<br />$ 10,000,000
<br />X POLICY PRO-❑
<br />ECT OC
<br />PRODUCTS - COMPIOP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />MWTB 31363521
<br />06/01/2021
<br />06101/2022
<br />Ea eBINEDISINGLE LIMIT
<br />$ 1,000,000
<br />X
<br />ANY AUTO
<br />BODILY INJURY (Per person)
<br />$
<br />OWNED SCHEDULED
<br />BODILY INJURY (Par medical
<br />$
<br />AUTOS ONLY AUTOS
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPE /dent) AGE
<br />Per accident
<br />$
<br />UMBRELLA DAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED I I RETENTIONS
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />MWC 313638 21 (ADS)
<br />/0112021
<br />0610112022
<br />X PER OTH,
<br />AND EMPLOYERS'LIABILITY YIN
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />_
<br />$ 1,000,000
<br />ANYPROPRIETOWPARTNERIEXECUTIVE FFOEWMEMBEREXCLUDED7 �
<br />NIA
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />E.L. DISEASE -POLICY LIMIT
<br />$ 1,000,000
<br />DESCRIPTION OF OPERATIONS below
<br />A
<br />Excess Workers' Compensation I
<br />MWXS 31363921 (OH,WA)
<br />0610112021
<br />0610112022
<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 I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached If more space Is required)
<br />Re, City of Santa Ana Municipal Facililies License Agreement.
<br />The City of Santa Ana, its officers, officials, employees and volunteers Ware included as Additional Insured under the General Liability policy but only with 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 bylaw. This insurance is primary with respect to the interest of the
<br />Additional Insured and any other insurance maintained by Additional Insured is excess and non-contributory with this insurance. Contractual Liability under the General Liability but only to the extent dictated by
<br />policy terms, exclusions, and conditions.
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<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 />AUTHORIZED REPRESENTATIVE
<br />of Marsh USA Inc.
<br />(01988.2016 ACORD C Immy
<br />FVao a e
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD i— Risk Management Analyst
<br />
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