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Home My WebLink AboutT-MOBILE US INC - INSURANCE CERTIFICATEII CERTIFICATE OF LIABILITY INSURANCE `� sn/2o14 DADDIYI'YY) 4/22//22/2013 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 INSURER(S), 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 terns 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 endomement(s). PRODUCER Lockton Companies,LLC-1 St. Louis Three CIPlace Drive, Suite 900 St. Louis M063141-7081 (314) 432-0500 CONTACT NAM hj AI C Ext: AIC No: IL EADDRL IN E B AFFORDING COVERAGE N IC e INSURER A: XL Insurance America, Inc. 24554 INSURED T-Mobile US, Inc. 1358772 Its Subsidiaries and Affiliates 12920 SE 38th Street Bellevue WA 98006 INSURER B: Greenwich Insurance Com anv 22322 INSURER C: National Union Fire Ins Co Pittsburgh PA 19445 INSURER D IN E: ER COVERAGES TMOBI CERTIFICATE NUMBER: 12218014 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 TR TYPE OF INSURANCE ADDL INSR SUBR IWE) POLICY NUMBER POLICY EFF MMI /YYYY POLICY EXP MM/DD/YYVY LIMITS B GENERAL LIABILITY Y Y RGD500025902 5/1/2013 5/1/2014 EACH OCCURRENCE 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FRI OCCUR DAMAGE TO RENTED PREMISES Ea occurrence 1,000,000 MED EXP (Any one rson 5,000 PERSONAL S ADV INJURY $ 1 000 OOO GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE POLI V LIMIT APPLIES PER PRO- JE T LOC PRODUCTS - COMP/OP AGG s ZOOOOOO $ lj B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS Y Y RAD500025702AOS RAD500025802MA 5/112013 5/1/2013 5/1/2014 $/I/2014 Eea11111DISINGLELIMIT E2000O00 X BODILY INJURY (Per Person) $ XXXXXXX BODILY INJURY Per a¢itlent ( 8 XXXXXXX HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per amdent $ XXXXXXX $XXXXXXX C C C X UMBRELLA UAB EXCESS LIAB X OCCUR CLAIMS -MADE Y N 20562091 SIR applies per policy terms & conditions 5/1/2013 5/1/2014 EACH OCCURRENCE s 5 000 000 AGGREGATE $ 5 00O 000 DED I X I RETENTION$ s XXXXXXX AANY WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN OFFICE PEMBIRRIPAFTNEPoEXECUrIVE OFFICERrM in MH) E%OLUDEDi N HM .dl oryln NH) nESCaesmce Omer DESCRIPTION OE WERATIONS Mbw NIA N RWD500030101 AIDS RWR500030201 WI 5/1/2013 5/1/2013 5/1/2014 5/12014 WC STATU- OTH- X TORYLIMITS EL. EACH ACCIDEM $ 1.000000 EL DISEASE - EA EM OVEE 1,000,000 ELDISEASE- POLICY LIMIT 1 OOO OOO DESCRI PION OF OPERATIONS / LOCATIONS I VEHICLES /(Attach ACORD 101, Additional Remarks Schedule, IT more space is required!) The Certificate I -(older and other entities defined are additional insureds on a primary and non-contributory basis under general liability and are additional insured under automobile liability as required by written Contract. Waiver of: ubrogation applies under general liability and automobile liability as required by written contract. **See Attached Endorsements** DNO3245A - 137 N Bryan Ave, Fun Collins, CO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 12218014 AUTHORIZED REPRESENTATIVE City of Fort Collins City Managger PO Box 580 300 Laporte Avenue Fort Collins CO 80522-0580 ACORD 25 (2010/05) ©1988- ORD COWOOUFMN. All rights reserved The ACORD name and logo are registered marks of ACORD ENDORSEMENT # 023 This endorsement, effective 12:01 a.m., May 1, 2013 forms a part of Policy No. RGD500025902 issued to T-MOBILE US, INC. by Greenwich Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification schedule shown below: Name of Person(s) or Entity(ies): "Blanket per list on file." Mailing Address: "Blanket per List on file" All other terms and conditions of the policy remain unchanged. Miscellaneous Attachment: M481510 Master ID: 1358772, Certificate 11): 12218014 Number of Days Advanced Notice of Cancellation: C (Authorized Representative) ENDORSEMENT # 003 This endorsement, effective 12:01 a.m., May 1, 2013 forms a part of Policy No. RAD500025702 issued to T-MOBILE US, INC. by Greenwich Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(s) according to the notification schedule shown below: Name of Person(s) or Entity(ies): "Blanket per list on file." Mailing Address: "Blanket per List on file" All other terms and conditions of the policy remain unchanged. Miscellaneous Attachment: M481533 Master ID: 1358772, Certificate ID: 12218014 Number of Days Advanced Notice of Cancellation: C (Authorized Representative)