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Digitally signed by Francine R.
<br />Francine R. Villareal Villareal
<br />Date: 2021.10.1913:22:29-07'00'
<br />ACORO° CERTIFICATE OF LIABILITY INSURANCE 5/l/2022
<br />DATE (MMIDDIYYYY)
<br />10/12/2021
<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 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 Lockton Companies
<br />CONT
<br />NAMEACT
<br />Three City Place Drive, Suite 900
<br />St. Louis MO 63141-7081
<br />(314)432-0500
<br />PHONE FAX
<br />Ext : A/C Na
<br />E-MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Continental Casualty Co=my
<br />20443
<br />INSURED T-Mobile US, Inc.
<br />1358772 Its Subsidiaries and Affiliates
<br />INSURER B: The Continental Insurance Company
<br />35289
<br />INSURER C : Transportation Insurance Company
<br />20494
<br />INSURER D :
<br />12920 SE 38th Street
<br />Bellevue WA 98006
<br />INSURER E
<br />INSURER F :
<br />COVERAGES TMOBI CERTIFICATE NUMBER: 12325146 REVISION NUMBER: 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
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MMIDD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />N
<br />7012343900
<br />5/l/2021
<br />5/1/2022
<br />EACH OCCURRENCE
<br />$ 10,000,000
<br />CLAIMS -MADE OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 10,000,000
<br />MED EXP (Any one person)
<br />$ 25,000
<br />PERSONAL & ADV INJURY
<br />$ 10,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 20,000,000
<br />POLICYEl JE � LOC
<br />PRODUCTS -COMP/OP AGG
<br />$ 20,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />N
<br />N
<br />7012343878
<br />5/t/2021
<br />5/l/2022
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 5,000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$ XXXXXXX
<br />ANY AUTO
<br />BODILY INJURY (Per accident)
<br />$ XXXXXXX
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />PROPERTY DAMAGE
<br />Per accident
<br />$ XXXXXXX
<br />HIRED NON -OWNED
<br />ONLY AUTOS ONLY
<br />$XXXXXXX
<br />B
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />N
<br />N
<br />CUE 7014886953
<br />5/l/2021
<br />5/1/2022
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />B
<br />B
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />Slit applies per policy
<br />terms & conditions
<br />AGGREGATE
<br />$ 5,000,000
<br />DED I X I RETENTION $ 10,000
<br />$ XXXXXXX
<br />1
<br />1
<br />B
<br />B
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
<br />OFFICER/MEMBER EXCLUDED? NI
<br />(Mandatory in NH)
<br />NIA
<br />N
<br />7012343895 (AOS)
<br />7012343881 CA
<br />7012447142 AZ,MA,OR,WI)
<br />5/1/2021
<br />5/l/2021
<br />5/l/2021
<br />5/1/2022
<br />5/1/2022
<br />5/1/2022
<br />PER OTH-
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 2,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 2,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 2,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TFRM(S) REFERENCED.
<br />The Certificate Holder and other entities defined by written contract, statute, permit application or written agreement are additional insureds on a primary and
<br />non-contributory basis under general liability and are additional insured tinder automobile liability as required by written contract. Waiver of Subrogation applies
<br />under general liability and automobile liability as required by written contract. **See Attached Endorsements** LA93010A/LA0620A - 2115 W Mcfadden Ave Santa
<br />Ana, CA 92704
<br />12325146
<br />City of Santa Ana
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
<br />CANCELLED BEFORE
<br />Exec. D1reClOre, Parks, BCC. & Community Services
<br />y
<br />THE EXPIRATION DATE THEREOF,
<br />NOTICE WILL
<br />BE DELIVERED IN
<br />Attn: Risk Management Division
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza
<br />.Santa Tina CA 92702
<br />AUTHORIZED REPRIESENTAT
<br />,,, oRaNc
<br />RA Mwag'tM erd DiVisi n
<br />REVIEWED & APPROVED BY:
<br />© 1988-2 ACORD C
<br />L
<br />v�
<br />ACORD 25 (2016/03) The ACORD name and logo
<br />are registered marks of ACORD
<br />`
<br />Risk Management Analyst
<br />
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