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I DATE IMMIDDNYYYI......
<br />! �CERTIFICATE OF LIABILITY INSURANCE 5/1/201.7 8/24r20I6
<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 pol"Icy(ies) 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 />TCT
<br />PRODUCER Lockton Companies NANMEE:
<br />Three City Place thrive, Suite: 900 PHONE FAX
<br />ArC N9-J5xf _._.-._,_.
<br />St. Louis MO 63141-7081 E-MAIL
<br />(31.4) 432-0500 ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE NAIL #
<br />..INSURED
<br />INSURER A: XL InSLlrance America, Inc.
<br />24554
<br />T-Mobile US, Inc.
<br />INSURER B: Greenwich InSUrance Company
<br />22322
<br />1.358772 Its Subsidiaries and ,Affiliates
<br />INSURER C: National Union hire Ins Co Pitts. ['A
<br />19445
<br />12920 SE 38th Street
<br />INSURER D
<br />Bellevue: WA 98000
<br />INSURER E
<br />. ^,-""'Z) `1 �*),..I -- 4»`4s d.@..',,+.
<br />...... ___.
<br />........ ..
<br />k
<br />INSURER F :
<br />COVERAGES Tfv OBI CERTIFICATE NUMBER:
<br />171?5146 REVISION NUMBER:
<br />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 ._.. _.. .ADDLSUBR' _ _.. POLICYEFF POLICYEXP
<br />'.... LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER fMMIDDIYYYYI (MMIDDNYYYILIMITS
<br />B COMMERCIAL GENERAL LIABILITY Y N RGD5000259-05 '...5/1f2016 '. 5/112017
<br />EACH OCCURRENCE $ 1,.000,000
<br />._. CLAIMS MADE X, OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES (Ea occur excel 's 1,„000,000_
<br />MED FXP (Any one person) $ 5,,.000
<br />PERSONAL &ADV INJURY $ 1.„000,000
<br />GE,N'LAGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATEs 2,000,000
<br />POLICY JECOT- X.... LOG
<br />PRODUCTS-COMPPOP,AGO s 2,000,000.
<br />OTHER_
<br />s
<br />B
<br />AUTOMOBILE.
<br />LIABILITY t� f IPAD5f1C)1257'7W5 SIIJ2016 5/I12017
<br />,
<br />COMBINED SINGLE LIMIT
<br />$ ..,.
<br />fEa,aec�deetl 2.,.000,000.
<br />ANY AUTO
<br />BODILY INJURY (Per person) S XXXXXXX
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident) s XXXXXXX,
<br />HIRED NON -OWNED
<br />PROPERTY DAMAGE s X..'XXXXX
<br />AUTOS ONLY AUTOS ONLY
<br />(Per scodenl)
<br />$ XXXXXXX
<br />C X UMBRELLA LIAB X OCCUR N N 1.9086894 5111201.6 :. 511/2017
<br />EACH OCCURRENCE s 5,000,000.
<br />..
<br />0 EXCESS LIAR Sift applies per policy CLAIMS -MADE
<br />_.
<br />AGriREGATE... 5,.00,000
<br />--s
<br />C .._.m ......... ..__--- terrrus r31; conditions
<br />BED RETENTION25,000
<br />S XXXXXXX
<br />WORKERS COMPENSATION
<br />A AND EMPLOYERS' LIABILITY ° RWD5000301-04 AIDS 5111201.6 5/l/2017
<br />PER OTH-
<br />STATUTE ER
<br />YIN ftWRSdf)t130I 2-04W[ 5JU/206 5/1/2017
<br />A ANYPROPRIENH1
<br />ACCIDENT
<br />OEEMPLGYEE
<br />OFFICFRIMEMBERf EXCLUDED?ECUITtlVE
<br />N1a
<br />(Mandatory
<br />E LDISEASE S 1,,000,000,
<br />It yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT S 1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required)
<br />THIS CERTIFICATE SUPERSEDES,ALI, PREVIOUSLY ISSUED CERTIFICATES FORt1'111S t'IOUDER. APPI.ICABLE'TO THE C NRR.IERS ITS I`ED ANDTliF, POLICY
<br />TER,Nt(S1 REEERIENCED.
<br />The Certificate [-folder and other entities defined by written contract, stataite, Penn it application or written agreement are additional insureds on a primary and
<br />non-contributory baSiS under general liability and are additional insured Larder automobile liability as required, by written contract. Waiver of'Subrogation applies
<br />Linder general Liability and automobile liability as required by written contract. **See Attached Endorsements** LA93010A/LA0620A
<br />-'21 15 W Mcfidden Ave.,
<br />Santa Ana, CA 92704_
<br />CERTIFICATE HOLDER
<br />12325146
<br />City of Santa Ana
<br />Attn: City Attorneys Office
<br />20 Civic Center Plaza (M-23)
<br />PC) Box 1988
<br />Santa Ana CA 9'2702
<br />ACORD 25 (2016/03)
<br />N,, !C ' l_ irAv CANCELLATION See Attachments
<br />®q� p SHOULD
<br />EXPIRATII©NHABOVE
<br />DATE VTHEREOF, NOTICE POLICIES CANCELLED WILL BEBEFORE DELIVERED THEIN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />�yyq' 1
<br />W e
<br />AUTHORIZED REPRESENTATI]Vgr ._ .sI^!
<br />0
<br />rJ 1988.2MT'ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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