MA FY 0405-CS070102ACORD CERTIFICAT'
Jackson & Harmon Ins. Agency
510 N. Valley Mills Dr., #701
Waco TX 76710
OF LIABILITY INSURAW OP ID G DATE(MM/DDNWY)
PAVEM -1 01/02/07
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
Pavement Services Corporation
P. 0. Box 1107
Euless TX 76039 -1107
COVERAGES
INSURERS AFFORDING COVERAGE
NAIC #
INSURER A: Republic Lloyds Insurance Co.
19208
INSURER B: Southern Insurance Co.
19216
INSURER C: Republic Underwriters Ins. co.
GENERAL LIABILITY
24538
INSURER D:
A X X COMMERCIAL GENERAL LIABILITY TXP5643065 01
EACH OCCURRENCE
03/10/06 03/10/07
INSURER E:
CLAIMS MADE [g] OCCUR
S(E
PREMISEaoccurence)
THE PM lrlrQ nr ........ ___ _...___.__
FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
MAY O WHIICH THIS CERTIFICATE IF CATE MAY BE ISSUED
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED
OR
SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
BY PAID CLAIMS.
LTRINSRC TYPE OF INSURANCE POLICY NUMBER
DATE MM/DD DATE MM/DD LIMITS
GENERAL LIABILITY
A X X COMMERCIAL GENERAL LIABILITY TXP5643065 01
EACH OCCURRENCE
03/10/06 03/10/07
$1,000,000
CLAIMS MADE [g] OCCUR
S(E
PREMISEaoccurence)
$300,000
MED EXP (Any one person)
$ 10,000
PERSONAL &ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
$ 2 , 000 , 000
POLICY X JECT LOC
PRODUCTS - COMP /OP AGG
$2,000,000
AUTOMOBILE
LIABILITY
X
B
ANY AUTO
TCA5643066 01
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 EA ACC
$
AUTO ONLY: AGG
$
EXCESS/UMBRELLA LIABILITY
C X OCCUR ā¯‘CLAIMS MADE UMB5645964 00
EACH OCCURRENCE
03/10/06 03/10/07 AGGREGATE
. $5,000,000
$5,000,000
DEDUCTIBLE
X RETENTION $10,000
WORKERS COMPENSATION AND
$
EMPLOYERS' LIABILITY
B
X TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE WC5643067 01
OFFICER/MEMBER EXCLUDED?
03/10/06 03/10/07 E.L. EACH ACCIDENT
$ 1,000,000
If yes, describe under
E.L. DISEASE - EA EMPLOYEE
$ 1 , 000 000
SPECIAL PROVISIONS below
,
OTHER
E.L. DISEASE - POLICY LIMIT
$1,000,000
A Equipment Floater TXP5643065 01
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
C I TCO 3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOi
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Garreth Campbell p
City of C NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
255 Parkway Blvd. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Coppell TX 75019 REPRESENTATIVES.
AGUKLB Z5 (2001/08)
1988