Qwest-CS090925ACORd' CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYM
P2ODUCER 09/25/2009
Marsh USA, Inc. THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION
1301 5th Avenue, Suite 1900 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Seattle, WA 98101 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Attn: Kathy Hadri 206 214 3119 Fax: 206 214 3483 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
100429- QCC -GAW -09-10 cunt none
;INSUR;ERA: S AFF;Union G COVERAGE NAIC #
INSURED
QWEST COMMUNICATIONS COMPANY LLC Nationa Fire Ins Co Pittsburgh PA 19445
1801 CALIFORNIA STREET, SUITE 1150 INsuRER B. Insurance Company Of The State Of PA 19429
DENVER, CO 80202
INSURER C:
INSURER D:
INSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
D.
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
VS ADD'
TR INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTNE POLICY EXPIRATION
A X GENERAL LIABILITY DATE (MMIDDIYYYY) DATE (MMIDD/YYYY) LIMITS
GLO939667 10/01/2009 10/01/2010 EACH OCCURRENCE nnn
)(I COMMERCIAL GENERAL LIABILITY =
CLAIMS MADE [K] OCCUR
EXCESS / UMBRELLA LIABILITY
OCCUR D CLAIMS MADE
DEDUCTIBLE
RETENTION $
CA0936289 (AOS)
CA6506174(CT)
CA6506175 (MA)
CA6506176 (VA)
B WORKERS COMPENSATION AND WC4289042 (AO:
B EMPLOYERS' LIABILITY ERr WC4289043 (CA)
ANY B OFFICERIMEMBEREXXCLUDED? ECUTIVE Y / N WC4289044 (FL)
A Mandato in NH ff es � WC4289045 (OR)
�..,�,.... 2'__...1._Y yes. under
PREMISES Ea o=,anoe
GENERAL AGGREGATE LIMIT APPLIES PEF
MED EXP (Any one person)
POLICY M -
JECT LOC
A
AUTOMOBILE
LIABILITY
A
X
ANY AUTO
A
ALL OWNED AUTOS
A
$
SCHEDULED AUTOS
$
X
HIRED AUTOS
X
NON -OWNED AUTOS
$
X
SELF - INSURED FOR
AUTO PHYSICAL DAMAGE
GARAGE
LIABILITY
ANY AUTO
EXCESS / UMBRELLA LIABILITY
OCCUR D CLAIMS MADE
DEDUCTIBLE
RETENTION $
CA0936289 (AOS)
CA6506174(CT)
CA6506175 (MA)
CA6506176 (VA)
B WORKERS COMPENSATION AND WC4289042 (AO:
B EMPLOYERS' LIABILITY ERr WC4289043 (CA)
ANY B OFFICERIMEMBEREXXCLUDED? ECUTIVE Y / N WC4289044 (FL)
A Mandato in NH ff es � WC4289045 (OR)
�..,�,.... 2'__...1._Y yes. under
PREMISES Ea o=,anoe
$ 1,000,000
MED EXP (Any one person)
$ 10,000
PERSONAL & ADV INJURY
GENERAL AGGREGATE
$ 1,000,000
¢ nnn nnn
10/01/2009
10/01/2009
10/01/2009
10/01/2009
10/01/2010
10/01/2010
10/01/2010
10/01]EACH
COMBINED SINGLE LIMIT
(Ea accident)
$ 2,000,000
BODILY INJURY
r person)
$
DILY INJURY
r accident)
$
OPERTY DAMAGE
r accident)
$
O ONLY - EA ACCIDENT
$
ER THAN EA ACC
O ONLY:
AGG
$
$
OCCURRENCE
$
REGATE
10/01/2009 1
10/01/2010 r
STATU- OTH-
r..L.DISEASE S
1,000,000
OTHER
EASE - POLICY LIMIT $ 11000,000
B Workers' Compensation /EL WC4289046 (TX) 10/01/2009 10/01/2010 Each Acc/Emp /Policy Limit $1,000,000
A Workers' Compensation /EL WC4289047 (ND OH WI WY) 10/01/2009 10/01/2010 Each Acc/Emp /Policy Limit
A XS Workers' Compensation /EL XWC0899047 WA $1,000,000
( ) 10/01/2009 10/01/2010 Excess of $1,000,000 SIR $1,000,000
DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
I
RES ECTS THEIR PINTEREST INITHE ORATIONS INSURED
OF THE NAMED INSURED AS REQUIRED BY WRITTEN CONTRACT.URED ENDORSEMENT AS
CFRTICIf-eTr_ unp ---
—° =A-UU1
CITY OF COPPELL
ENGINEERING DEPARTMENT
255 PARKWAY BOULEVARD
COPPELL, TX 75019
ACORD 25 (2009/01)
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND
UPON THE INSURER, ITS AGENTS nw 0 ..... — —.—
Cheryll L. Koch
&4(A—
wa r+a.vr%u %uKFUKATION. All Rights Reserved
The ACORD name and logo are registered marks of ACORD
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
This Certificate of Insurance 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.