Qwest-CS081002, CORD -, C E RT I F I CAT E O F LIABILITY I N S U RAN C E
M/DD/YYY)
10 /02/ loos
PRODUCER
Marsh USA, Inc.
1301 5th Avenue, Suite 1900
Seattle, WA 98101
Attn: Kathy Hariri 206 214 3119 Fax: 206 214 3483
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.
100429- QCC- GAW -08 -09 cunt none
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
INSURER A: National Union Fire Ins Co Pittsburgh PA
19445
QWEST COMMUNICATIONS CORPORATION
1801 CALIFORNIA STREET, SUITE 1150
INSURER B: Insurance Company Of The State Of PA
19429
DENVER, CO 80202
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
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.
NS
LTR
ADD
INSR
TYPE OF INSURANCE
POLICY NUMBER
OLICY EFFECTIVE
DATE (MM /DDIYY)
POLICY EXPIRATION
DATE (MM /DDIYY)
LIMITS
A
X
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
GL1871962
10/01/08
10/01/09
EACH OCCURRENCE
1 000 00
DAMAGE TO RENTED
PREMISES Ea occurence
$ 1,000,00
MED EXP (Any one person)
$ 10,00
CLAIMS MADE � OCCUR
PERSONAL & ADV INJURY
$ 1,000,00
GENERAL AGGREGATE
$ 2,000,00
GENERAL AGGREGATE LIMIT APPLIES PER
POLICY PRO LOC
JECT
PRODUCTS - COMP /OP AG
2,000,00
A
A
A
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
CA6077462 (AOS)
CA6077463(CT)
CA6077464(MA)
CA6077465 VA
( )
10/01 /08
10/01/08
10/01/08
10/01/08
10/01/09
10/01/09
10/01/09
10/01/09
COMBINED SINGLE LIMIT
(Ea accident)
$ 2,000,00
BODILY INJURY
(Per person)
$
X
HIRED AUTOS
BODILY INJURY
(Per accident)
$
X
X
NON -OWNED AUTOS
SELF - INSURED FOR
PROPERTY DAMAGE
(Per accident)
$
AUTO PHYSICAL DAMAGE
GARAGE
LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY: AGG
$
$
EXCESS /UMBRELLA LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
OCCUR F-1 CLAIMS MADE
$
$
DEDUCTIBLE
RETENTION $
B
B
B
A
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
If yes descr be under
SPECIAL PROVISIONS below
WC4800675 (AOS)
WC4800676 (CA)
WC4800677 (FL)
WC4800678 (OR)
10/01/08
10/01 /08
10/01/08
10/01/08
10/01/09
10/01/09
1 O /O1 /O9
10/01/09
C
X W STATU-
L. EACH ACCIDENT tH-
$ 1,000,00
L. DISEASE - EA EM
$ 1,000,00
L. DISEASE - POLICY LIMIT
$ 1,000,00
B
A
A
OTHER
Workers' Compensation
Workers' Compensation
Excess Workers' Compensation
WC4800679 (TX)
WC4800680 (ND, OH, WI, WY)
XWC4801276 (WA)
10/01/08
10/01/08
10/01/08
10/01/09
10/01/09
10/01/09
SIR Each Acc/Emp $1,000,000
SIR Each Acc/Emp $1,000,000
Excess of SIR $1,000,000
DESCRIPTION OF OPERATIONS /LOCATIONSIVEHICLES /EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
THE CITY OF COPPELL, TEXAS IS AN ADDITIONAL INSURED AS RESPECTS THEIR INTEREST IN THE OPERATIONS OF THE NAMED INSURED AS
REQUIRED BY WRITTEN REGARDING GENERAL LIABILITY COVERAGE.
CERTIFICATE HOLDER SEA - 001093320 -09 CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
CITY OF COPPELL
ENGINEERING DEPARTMENT
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
255 PARKWAY BOULEVARD
COPPELL, TX 75019
BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND
UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
aRIZ%jTR�ESENTATNE �} �� � a�
(.Il
ACTH
CheeryllllhhLll. Koch
. At+l10r% rnonnDATrnAI 4GRA
ACORD 25 (2001 /05)
IMPORTANT
If the certificate holder is an ADDITIONAL !NSURED, 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.
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