Qwest-CS120820CERTIFICA
TE OF LIA
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND !o Y INSURANCE DATE (MM /DD/YYyy)
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE UPON 08/20/2012
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE N THE CERTIFICATE HOLDER. THIS
°RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. COVERAGE AFFORDED BY THE POLICIES
'ORTANT: If the certificate holder is an ADDITIONAL INSURED, the olio ISSUING INSURER(S), AUTHORIZED
the terms and conditions of the policy, p y(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
certificate holder in lieu of such endorsement�s� Policies may require an endorsement. A statement on this certificate does not confer rights to the
PRODUCER
Marsh USA Inc. CONTACT
CA License #0437153 NAME:
13015th Avenue, Suite 1900 PHONE
Seattle, WA 9$101 -2682 -M o FAX
E -MAIL
Attn: Seaftle.certrequest@marsh.com / Fax: 212 -948 -4326 ADDRESS: A/C No
J13913- QCC- GAW -12 -13
INSURED --- INSURER S AFFORDING COVERAGE
none INSURER A. Greenwich Insurance Company NAIC #
CenturyLink, Inc.; Embarq Corporation;
Qwest Communications International Inc.; INSURER B: XL Insurance Company of America 22322
and Any Affiliated, Subsidiary & Associated Companies
Including Qwest Communications Company LLC INSURER c : XL Specialty Insurance Company
931 14th St., 10th Floor INSURER D : 37$$5
Denver, CO 80202 INSURER E:
CERTIFICATE NUMBER: ENSURER F
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A
SEA- 002239566 -13 REVISION NUMBER: 19 2111 7 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ABOVE FOR THE POLICY PERIOD
INSR WITH RESPECT TO WHICH THIS
LTR TYPE OF INSURANCE ADDL SUBR S SUBJECT TO ALL THE TERMS,
A GENERAL LIABILITY POLICY NUMBER POLICY EFF POLICY EXP
X Rrnrnnnvjo
COMMERCIAL GENERAL LIABILITY
09/01/2012 09/01/2013 LIMITS
CLAIMS -MADE � OCCUR
EACH OCCURRENCE $
DAMAGE
1'00�'0O(
TO RENTED ------
PREMISES Ea occurrence $
1,000,000
MED EXP (Any one person) $
10,000
GEN'L AGGREGATE LIMIT APPLIES PER
PERSONAL & ADV INJURY $
11000,000
X POLICY PRO- X
GENERAL AGGREGATE $
2, 000,000
LOC
AUTOMOBILE LIABILITY
PRODUCTS - COMP /OPAGG $
2,000,000
X
RAD5000334 - ADS
ANY AUTO
X ALL OWNED
RAD5000335 - MA
09/01/2012 $
09/01/2013 COMBINED SINGLE LIMIT
Ea a
SCHEDULED
AUTOS AS
X
Auto Physical Damage - Self Insured
09/01/2012 cidont
09/01/2013 BODILY INJURY (Per
2,000,000
HIRED AUTOS X NON -OWNED
person) $
AUTOS
BODILY INJURY (Per accident) $
Y DAMAGE
UMBRELLA LIAg
PerOa c d $
EXCESS LIAB OCCUR
$
DED RFTF CLAIMS -MADE
Nnnu c
EACH OCCURRENCE $
WORKERS COMPENSATAND EMPLOYERS' LIA RWD5000329 A( ANY PROPRIETOR /PARUTIVE Y / N RWR5000330 WI OFFICER /MEMBER EXC M N/A
(Mandatory in NH)
If Ves. d.7iF
Workers' Compensation /EL
Workers' Compensaton/EL
RWE5000331- WA
RWE500332 OH
09/01 /2012
09/01/2012
3
EL EACH ACCIDENT
E.L. DISEASE - EA EM
E.L. DISEASE -POLICY L
Excess of $1,000,000 SIR
09/01/2012 09/01/2013 Excess of $1,000,000 SIR $1,000,000
:SCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schetlule, if more space is required)
E CITY OF COPPELL, TEXAS IS AN ADDITIONAL INSURED PER THE GENERAL LIABILITY BLANKET ADDITIONAL INSURED ENDORSEMENT AS RESP $1,000,000
THE NAMED INSURED AS REQUIRED BY WRITTEN CONTRACT.
ECTS THEIR INTEREST IN THE OPERATIONS
$ 11000,000
$ 1,000.000
CITY OF COPPELL
ENGINEERING DEPARTMENT
255 PARKWAY BOULEVARD
COPPELL, TX 75019
)RD 25 (2010/05)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Of Marsh USA Inc.
Cheryll L. Koch
@ 1988-2010
The ACORD name and logo are registered marks of ACORD ACORD CORPORATION. All rights reserved.