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Time Warner-CS07120101/08/2004 11:18 CITY OF COPPELL ENGR. DEPT. 4 92143207559 RIGHT -OF -WAY MAINTENANCE USE FEE Ordinance No. 2001 -944, Sec. 6 -14 -3. Registration Form for Service Provider NO.979 P02 Registration expires March 1 of every other year after the calendar year in which the first registration occurs. If registration is not renewed by the expiration date, after written notice from the City, the facilities of the service provider will be deemed to have been legally abandoned Service Provider (include any business name provider operates under or bas operated under for past 5 years) Comcast Cable of Indiana /Michigan /Texas, Inc. PUC Certificate Number (for cerdficated telecommuikations providers) City of Coppell License Ordinance No. Contact Names/Numbers 2110 -944 Mike Rassmusen 214- 320 -5455 Dottie Kelly 214- 320 -7529 Contractor(s) Name SEE ATTACHED LIST Contact Information. Emergency Contact Local Management Center 877- 833 -6350 Liability Insurance Carrier Marsh USA Inc. (Sec. 6 -14 -3 (h)) Attach proof of coverage Plans of Record provided to Engineering Dept. for existing facilities Y N For proposed facilities Y N Forward registration form and fee to Engineering Dept., City of Coppell, 255 Parkway Blvd., Coppell TX 75019 For Qgj ce e flN. :.:'..: Registration- V..O pa�`c�``.:': ............. .:..:........ . PRODUCER MARSH USA INC. TWO LOGAN SQUARE PHILADELPHIA, PA 19103 -2797 Attn: Comcast.Certs @marsh.com Fax: 212 -948 -0360 05194 - ALL - GAWU -07 -08 COMIC IRVING TX INSURED COMCAST CABLE OF INDIANA/MICHIGAN/ TEXAS, INC. 2951 KINWEST PARKWAY IRVING, TX 75063 CERTIFICATE NUMBER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES DESCRIBED HEREIN. COMPANIES AFFORDING COVERAGE COMPANY A DISCOVER PROPERTY & CASUALTY INSURANCE COMPANY COMPANY B ACE PROPERTY & CASUALTY INS CO COMPANY C FIDELITY & GUARANTY INS. CO. COMPANY D N/A THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO T TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM /DD/YY) POLICY EXPIRATION DATE (MM /DDfYY) LIMITS AUTO ONLY - EA ACCIDENT GENERAL LIABILITY OTHER THAN AUTO ONLY: _ GENERAL AGGREGATE $ 25,000.000 X PRODUCTS - COMP /OPAGG $ 6,000,000 A COMMERCIAL GENERAL LIABILITY CLAIMS MADE 1XI OCCUR D001Q00048 12/01/07 12/01/08 1 I 12/01/08 PERSONAL & ADV INJURY $ 1,900,000 AGGREGATE EACH OCCURRENCE $ 1,900,000 $ OWNER'S & CONTRACTOR'S PROT WORKERS COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ X INCL PARTNERS/EXECUTIVE I - -- OFFICERS ARE: EXCL D001WO0403 (AOS) D001W00404 (OR,WI) D001WO0405 (NJ) 12/01/07 I +' 2/01/0] 12/01/07 12/01/08 12/01/08 12/01/08 FIRE DAMAGE (Any one fire) $ 1,900,000 EL EACH ACCIDENT $ 2,000,000 EL D!sEASF- POLICY LIMIT $ 2.000,000 jEL DISEASE -EACH EMPLOYEE X $100,000 SIR MED EXP (Any one person) $ 10,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 10,000,000 X A ANY AUTO D001AO0340 (AOS) 12/01/07 12/01/08 BODILY INJURY (Per person) $ A ALL OWNED AUTOS SCHEDULEDAUTOS D001A00341 (MA) D001A00342 (TX) 12/01/07 12/01/07 12/01/08 12/01/08 BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Is — DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES /SPECIAL ITEMS CITY OF COPPELL IS INCLUDED AS ADDITIONAL INSURED AS RESPECTS THE GENERAL LIABILITY POLICY WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED. $100,000 PER OCCURENCE SELF INSURED RETENTION APPLIES ONLY TO THE ABOVE GENERAL LIABILITY POLICY. SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE HALL ENDEAVOR TO MAIL 'in DAYS WRITTEN NOTICE TO THE CITY OF COPPELL CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR P.O. BOX 478 COPPELL, TX 75019 LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE ISSUER OFTHIS CERTIFICATE. MARSH USA INC. BY: Mary Radaszewski MM1(3la2 }: VALID AS OF:11/30/07 GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: _ EACH ACCIDENT $ AGGREGATE $ B EXCESS LIABILITY X UMBRELLA FORM OTHER THAN UMBRELLA FORM XOO G23792254 12/01/07 12/01/08 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 $ C C A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ X INCL PARTNERS/EXECUTIVE I - -- OFFICERS ARE: EXCL D001WO0403 (AOS) D001W00404 (OR,WI) D001WO0405 (NJ) 12/01/07 I +' 2/01/0] 12/01/07 12/01/08 12/01/08 12/01/08 OTH X OR LIMITS ER EL EACH ACCIDENT $ 2,000,000 EL D!sEASF- POLICY LIMIT $ 2.000,000 jEL DISEASE -EACH EMPLOYEE $ 2,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES /SPECIAL ITEMS CITY OF COPPELL IS INCLUDED AS ADDITIONAL INSURED AS RESPECTS THE GENERAL LIABILITY POLICY WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED. $100,000 PER OCCURENCE SELF INSURED RETENTION APPLIES ONLY TO THE ABOVE GENERAL LIABILITY POLICY. SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE HALL ENDEAVOR TO MAIL 'in DAYS WRITTEN NOTICE TO THE CITY OF COPPELL CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR P.O. BOX 478 COPPELL, TX 75019 LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE ISSUER OFTHIS CERTIFICATE. MARSH USA INC. BY: Mary Radaszewski MM1(3la2 }: VALID AS OF:11/30/07 MARSH ,,, ..d#RTNIFI CATS FINSURM4kE- CERTIFICATE NUMBER CLE- 001184438 -05 PRODUCER THIS CERTIFICATE IS ISSUED AS AMATTER OF INFORMATION ONLY AND CONFERS MARSH LISA INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE TWO LOGAN SQUARE POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE PHILADELPHIA, PA 19103 -2797 AFFORDED BY THE POLICIES DESCRIBED HEREIN. Attn: COMCAST.CERTS @MARSH.COM FAX: (212) 948 -0360 COMPANIES AFFORDING COVERAGE COMPANY 5194 - ALL - CAS -05 -06 COMC IRVING TX A DISCOVER PROPERTY & CASUALTY INSURANCE COMPANY INSURED COMPANY COMCAST CABLE OF INDIANA /MICHIGAN/ TEXAS, INC. B DISCOVER SPECIALTY INSURANCE COMPANY COMPANY 2951 KINW EST PARKWAY IRVING, TX 75063 C NATIONAL UNION FIRE INS CO OF PITTSBURGH, PA COMPANY D FIDELITY & GUARANTY INS. CO. CCIVERAGES This certifies #�� Oersedes ariii l i es any oiov }jssued c rii # for the peiicy peririd n rt d ksslocn ,.:. THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED.. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDIYY) POLICY EXPIRATION DATE (MMIDDIYY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ 25,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE IK OCCUR D002QO0136 12/01/05 12/01/06 PRODUCTS - COMP /OP AGG $ 6,000,000 PERSONAL & ADV INJURY $ 1,900,000 EACH OCCURRENCE $ 1,900,000 OWNER'S & CONTRACTOR'S PROT FIRE DAMAGE (Any one fire) $ 1,900,000 X $100,000 SIR ME EXP (Any one person) $ 10,000 A AUTOMOBILE LIABILITY ANY AUTO D002AO0451 (AOS) 12/01/05 12/01/06 COMBINED SINGLE LIMIT $ 10,000,000 X A B ALL OWNED AUTOS SCHEDULEDAUTOS D002AO0452(MA) D002AO0453 (TX) 12/01/05 12/01/05 12/01/06 12/01/06 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: _ ANY AUTO EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ 5,000,000 C %� UMBRELLA FORM BE4485046 12/01/05 12/01/06 AGGREGATE $ 5,000,000 $ OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC STATU- OTH- X TORY LIMITS ER D D002WO0497 (AOS) 12/01/05 12/01/06 EL EACH ACCIDENT $y � 2,000,000 D A THE PROPRIETOR/ X INCL PARTNERS /EXECUTIVE OFFICERS ARE: EXCL D002W 00499 (OR/WI) D002WO0498(NJ) 12/01/05 12/01/05 12/01/06 12/01/06 EL DISEASE - POLICY LIMIT $ 2,000,000 EL DISEASE -EACH EMPLOYEE $ 2,000,000 OTHER DESCRIPTION OF OPERATIONS /LOCATIONSIVEHICLESISPECIAL ITEMS CITY OF COPPELL IS INCLUDED AS ADDITIONAL INSURED AS RESPECTS THE GENERAL LIABILITY POLICY WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED. $100,000 PER OCCURENCE SELF INSURED RETENTION APPLIES ONLY TO THE ABOVE GENERAL LIABILITY POLICY. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL ___M DAYS WRITTEN NOTICE TO THE CITY OF COPPELL P.O. BOX 478 CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR COPPELL, TX 75019 LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE ISSUER OF THIS CERTIFICATE. MARSH USA INC. BY: Mary Radaszewski� MM1 (3102) VALID AS OF: 01/04/06