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MA FY 0405-CS060309AC CERTIFICAT'' OF ' PRODUCER Jackson & Harmon Ins. Agency 510 N. Valley Mills Dr., #701 Waco TX 76710 LIABILITY INSURAN' i OP ID G DATE(MM/DD/YY1fY) PAVE -1 03/09/06 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone:254- 772 -6074 Fax:254- 772 -6864 INSURED INSURERS AFFORDING COVERAGE NAIC # BY PAID CLAIMS. INSURER A: Rep ublic Insurance Company 38318 INSURER B: Rep ublic Insurance Group 38318 Pavement Services Corporation PO Box 1107 Euless TX 76039 -1107 INSURER C: Southern Insurance Co. 19216 INSURER D: CLAIMS MADE OCCUR COVERAGES $300,000 INSURER E: MED EXP (Any one person) THE P01 ICIG2 nr 1e 1 ­­1 ��T . ...... ...... ... ._ ____.._ _. __ ITHSTAN ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT WHICH THIS CE 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTRINSRE TYPE OF INSURANCE POLICY NUMBER DATE MM/DD IV DATE MM /DD LIMITS GENERAL LIABILITY A X X COMMERCIAL GENERAL LIABILITY TXP564306501 EACH OCCURRENCE 03/10/06 03/10/07 $1, 000 , 000 CLAIMS MADE OCCUR P REMISES(Eaoccuren ce) $300,000 u MED EXP (Any one person) $ 10 0 0 0 i PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JECT LOC PRODUCTS - COMP /OPAGG $2,000,000 AUTOMOBILE LIABILITY a smog a X C ANY AUTO TCA564306601 03/10/06 03/10/07 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY (Per accident) $ NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY AGG $ EXCESS/UMBRELLA LIABILITY B X OCCUR F CLAIMSMADE LTMB564596400 EACH OCCURRENCE 03/10/06 03/10/07 AGGREGATE $5,000,000 $5 DEDUCTIBLE X RETENTION $ 10000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE WC564306701 _ TORY LIMITS ER 03/10/06 03/10/07 E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - EA EMPLOYEE $1,000,000 OTHER E.L. DISEASE - POLICY LIMIT $1,000,000 A Equipment Floater TXP564306501 03/10/06 03/10/07 Limit 1,015,386 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Deductibl 1,000 Certificate holder is named as additional insured on general liability. Waiver of Subrogation in favor of certificate holder on general liability and workers compensation. CERTIFICATE HOLDER CANCELLATION CITCO -3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN City of Coppell NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL ATTN: Garreth Campbell 255 Parkway Blvd. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Coppell TX 75019 REPRESENTATIVES. At.;UKU 25 (2001108) © ACORD CORPORATION 1 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08)