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acoR6' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDI(YI'Y) ll 5/1/2017 4/13/20I6 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 Lockton Companies Three City Place Drive, Suite 900 St. Louis MO 63141-7081 (314)432-0500 CON NAME: T A/C, No, Ezt: AJC' No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIL id INSURER A: XL Insurance America, Inc. 24554 INSURED T-Mobile US, Inc. 1358772 Its Subsidiaries and Affiliates F'a--co2%,I� i„ (T 11 12920 BE 38th Street INSURER B: Greenwich Insurance Company 22322 INSURER C: NRtional Union Fire Ins Co Pins, PA 19445 -- NSURERD: Bellevue WA98006 _- INSURER E INSURER F : COVERAGES TMOBI CERTIFICATE NUMBER: 12325146 REVISION NUMBER: XXXXXXX 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 ADDL INSD SUBR MD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP (MMIDDlci LIMITS B X COMMERCIAL GENERAL LIABILITY y Y RGD5000259-05 5/1/2016 5/1/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEnOCCUR LLnJJ PREMISES Ea occurrence $ 1 000000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT �LOC GENERAL AGGREGATE $2000000 PRODUCTS-COMP/OP AGG $ 2,000000 is OTHER B AUTOMOBILE LIABILITY y Y RAD5000257-05 5/1/2016 5/1/2017 Ee BINEaccIde� SINGLE LIMIT $ 2,000,000 X BODILY INJURY (Per Fecund) $ XX.XXXXX ANY AUTO AUTOS NCO AUTULED BODILY INJURY (Per accident $ XXXXXXX HIRED AUTOSPSCHEDNON OSWNED PROPER accden DAMAGE $ XX)CX}.i{X $XXXXXXX _ C G C X UMBRELLA LIAR EXCESS LIAR X OCCUR CI -AIMS -MADE ADE Y N 19096894 SIR applies per policy terms & conditions 5/1/2016 5/1/2017 EACH OCCURRENCE S 5 000 000 AGGREGATE $ 5 OOO OOO DEO X RETENTION $25,000 $ XXXXXXX A `� WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICEWMEMBER EXCLUDED4 (Mandatory in NH) f yes, describe Antler DESCRIPTION OF OPERATIONS below NIA N RV✓D500030-04 WI R{NRSON0302-g4 W1 5/1/2016 5/1/2016 5/1/2017 5/1/2017 PER OTH- X STATUTE E.L. EACH ACCIDENT $ I OOO,OOO E.L, DISEASE -EA EMPLOYEE I OOO OOO E.L. DISEASE POLICY LIMIT R 1000000 {gyp DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Addition marks Bob are, by be did If more space is required) The Certificate Bolder and other entities defined by written contract, statute, ppermit application orri we e tlitional insureds on a primary and non-conh'ibutory basis tinder general liability and are additional insured under automobile liability as required by MIT n r tr ryyEEpp Subrogation applies under general liability and automobile liability as regwred by writteu contract. **See Attached Endorsements** Re: Site #: LA I �^l%fadden Ave., Santa Ana, CA 92704GIs CERTIFICATE HOLDER CANCELLATION See Attachments SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 12325146 AUTHORIZED REPRESENTATIVE City of Santa Ana -City Attorneys Office 20 Civic Center Plaza (M-23) PO Box 1988 Santa Ana CA 92702 ei__ ACORD 25 (2014101) ©1988-htPIiCORD CO7TP—ORArZN. All rights reserved The ACORD name and logo are registered marks of ACORD