Qwest-CS060401CERTIFICATE
NUMBER
PRODUCER SEA- 000403012 -06
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
Marsh USA IDC.
NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
The Financial Center
POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
Avenue, Suite 2300
Seattle, WA 98161 -1Fourth AFFORDED BY THE POLICIES DESCRIBED HEREIN.
095
Attn: Kathy B. Hariri 206 613 -2625 Fax: 206 613 -2516 COMPANIES AFFORDING COVERAGE
COMPANY
WLCI - QCC- GAW -06 -07 cunt KBH cg2026 A NATIONAL UNION FIRE INS CO OF PA
INSURED -- — __
COMPANY
QWEST COMMUNICATIONS CORPORATION B INSURANCE COMPANY OF THE STATE OF PA
1801 CALIFORNIA STREET, SUITE 1150
DENVER, CO 80202 COMPANY
C AMERICAN HOME ASSURANCE COMPANY
COMPANY
D
Rio l
:._,1 PR' "� , B t N
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.
T
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
DATE (MM /DD
DATE (MM /DDNY)
LIMITS
A
GENERAL
LIABILITY
SEE ATTACHED
04/01/06
10/01/07
COMMERCIAL GENERAL LIABILITY
GENERAL AGGREGATE
$ 2,000,000
X
PRODUCTS - COMP /OP AGG
$ 2,000,000
PERSONAL & ADV INJURY
$ 1,000,000
CLAIMS MADE OCCUR
OWNER'S &CONTRACTOR'S PROT
EACH OCCURRENCE
$ 1,000,000
FIRE DAMAGE (Any one fire)
$ 1,000,000
MED EXP (Any one person)
$ 5,000
A
AUTOMOBILE LIABILITY
SEE ATTACHED (AOS)
04/01/06
10/01/07
A
X ANY AUTO
SEE ATTACHED (TX)
04/01/06
10/01/07
COMBINED SINGLE LIMIT
$ 2,000,000
A
ALL OWNED AUTOS
SEE ATTACHED (VA)
04/01/06
10/01/07
BODILY INJURY
SCHEDULED AUTOS
(Per person)
$
X HIREDAUTOS
X
BODILY INJURY
$
NON -OWNED AUTOS
(Per accident)
X ELF - INSURED FOR
PROPERTY DAMAGE
$
UTO PHYSICAL DAMAGE
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
ANY AUTO
OTHER THAN AUTO ONLY.1�"
EACH ACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
UMBRELLA FORM
AGGREGATE
$
OTHER THAN UMBRELLA FORM
$
B
h10t2I�ERS COMPEr4SATION AND
EMPLOYERS' LIABILITY
SEE ATTACHED (AOS) 04/01/06
10/01/07
f"
X 1 TORY LIMITS
B
SEE ATTACHED (CA) 04/01/06
10/01/07
$ 1,000,000
EL EACH ACCIDENT
A
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
HEXCL
SEE ATTACHED (OR) 04/01/06
10/01/07
_
EL DISEASE - POLICY LIMIT
$ 1,000,000
B
OFFICERS ARE:
OTHER
SEE ATTACHED (FL) 04/01/06
10/01/07
EL DISEASE -EACH EMPLOYEE
$ 1,000,000
A Workers' Compensation SEE ATTACHED (ND,OH,WI) 04/01/06 10/01/07 Each Accident/Employee $1,000,000
A Workers' Compensation SEE ATTACHED (WV,WY) 04/01/06 10/01/07 Each Accident/Employee $1,000,000
C Excess Workers' Compensation ISEE ATTACHED (WA) 04/01/06 10/01/07 Excess of SIR Shown Above
DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /SPECIAL ITEMS $1,000,000
THE CITY OF COPPELL, TEXAS IS AN ADDITIONAL INSURED AS RESPECTS THEIR INTEREST IN THE
:::'ERATIONS OF THE NAMED INSURED AS
REQUIRED BY WRITTEN REGARDING GENERAL LIABILITY COVERAGE.
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
CITY OF COPPELL
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL A DAYS WRITTEN NOTICE TO THE
ENGINEERING DEPARTMENT
CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
255 PARKWAY BOULEVARD
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: Cheryll L. Ko ch
LID AS OFr -04/07/06
PRODUCER'
Marsh USA Inc.
The Financial Center
1215 Fourth Avenue, Suite 2300
Seattle, WA 98161 -1095
Attn: Kathy B. Hariri 206 613 -2625 Fax: 206 613 -2516
QWLCI - QCC- GAW -06 -07 cunt KBH
INSURED Cg2026
QWEST COMMUNICATIONS CORPORATION
1801 CALIFORNIA STREET, SUITE 1150
DENVER, CO 80202
POLICY TERM 4/1/06 TO 10/1/06
General Liability Policy #GL3917172
Automobile Liabilit• ✓:
Policy #C08064`3 (All Other States)
Policy #CA3780042 (Texas)
Policy #CA3768494 (Virginia)
Workers' Compensation:
Policy #WC4778329 (All Other States)
Policy #WC4777998 (California)
Policy #WC4778330 (Oregon)
Policy #WC4778331 (Florida)
Policy #WC4778332 (North Dakota, Ohio, Wisconsin, West Virginia, Wyoming
Excess Workers' Compensation Policy #XWC4778869 (Washington)
POLICY TERM: 10/1/06 TO 10/1/07
General Liability Policy #GL3948924
omobile Liability:
.cy #CA3818306 (All Other States)
rolicy #CA3817587 (Texas)
Policy #CA3817586 (Virginia)
Workers' Compensation:
Policy #WC6611392 (All Other States)
Policy #WC6611389 (California)
Policy #WC6611390 (Oregon)
Policy #WC6611391 (Florida)
Policy #WC6611393 (North Dakota, Ohio, Wisconsin, West Virginia, Wyoming)
Excess Workers' Compensation Policy #XWC6611394 (Washington)
ENGINEERING DEPARTMENT
255 PARKWAY BOULEVARD
COPPELL, TX 75019
COMPANY
E
COMPANY
F
COMPANY
G
COMPANY
H
MARSH USA INC. BY
Cheryll L. Koch
� � DATE (MM /DD/YY)
u °�
04/07/06
COMPANIES AFFORDING COVERAGE