HomeMy WebLinkAbout434510 T-MOBILE US INC - INSURANCE CERTIFICATE (2)Ac"RO• CERTIFICATE OF LIABILITY INSURANCE
16.�� 5/1/2016
DATE(MM/DD/YYYY)
4/16/2015
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 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 MO63141-7081
(314) 432-0500
CONTACT
NAME:
INC,PHONE FAX
No Ext : A/c No):
E-MAIL
ADDRESS
INSURERISI AFFORDING COVERAGE
INSURERA: XI. 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 Company
22322
INSURER C: National Union Fire Ins Co Pittsburgh PA
19445
INSURER D'
INSURER
INSURER
1`f1VGI2Af9=e TMi')Ri f`COTIFICATF NI IMRFR- 17') 1 Rfll d RFVICInki NI IMRFR• YYYYYYY
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
TYPE OF INSURANCE
ADDL
SUER WVD
POLICY NUMBER
POLICY EFF
POLIMMIDDIYYYY MMIDCY EXPim
DIYYYYI
LIMITS
B
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE O OCCUR
Y
Y
RGD5000259-04
5/1/2015
5/1/2016
EACH OCCURRENCE
1,000,000
DAMAGE TO RENTED n
1,000,000
MED EXP An one person)5,000
PERSONAL B ADV INJURY
$ 1000 000
GEN'L AGGREGATE LIMIT APPLIES PER.
POLICY JEC O LOC
OTHER
GENERAL AGGREGATE
$ 2 OOO OOO
PRODUCTS -COMPIOP AGG
$ 2,000,000
$
B
AUTOMOBILE
LIABILITY
ANY pAUTO
AUTOSNED AUTOSULED
HIRED AUTOS NON -OWNED
AUTOS(Per
Y
Y
RAD500025704
5/1/2015
5/1/2016
COMBINEDISINGLE LIMIT
$ 2,000,000
X
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident
${xxi'cx
PROPERTY DAMAGE
accident)
$ XX)CX3OC
C
C
C
X
UMBRELLA LIAB
EXCESS LAB
)(
OCCUR
CLAIMS -MADE
Y
N
1
19961923
SIR applies per policy
terms & conditions
1
5/1/2015
5/1/2016
EACH OCCURRENCE
$ 51000,000
AGGREGATE
$ 5.000.000
DED I X I RETENTION$ 25,000
$ XXXX}{}{}{
A
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNERrF]fECUTIVE Y/N
OFFICEI rMEMBER EXCLUDED?
(ManEaotry in NH)
If yes, d..ne under
DESCRIPTION OF OPERATIONS belay
N /A
N
RWD5000301-03 AOS
RWR5000302-03 WI
5/1/2015
5/1/2015
5/1/2016
5/1/2016
PER OTH-
X STATUTEEll
E.L. EACH ACCIDENT
$ 1 000 000
E.L. DISEASE - EA EMPLOYEE
1000 000
E.L. OISEA5E- POLICY LIMIT
1 00U 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, may be attached H more space is required)
The Certificate Holder 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 Subrogation applies under general liability and automobile liability as required
by written contract. **See Attached Endorsements" DN03245A - 137 N Bryan Ave, Fort Collms, CO
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.
1221 8014 AUTHORIZED REPRESENTATIVE
City of Fort Collins
City Manager
PO Box 580
300 Laporte CO 05 /'�— 19
Fort Collins CO 80522-0580 L! / / l
2n 25 f201A/011 Cc)1QRR_7" dwArnRn ('-ORISnRATInN All rinhtQ raearvari
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