Qwest-CS050329MARSH CERTIFICATE OF INSURANCE CERTIFICATE NUMBER
SEA-000403012-05
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
Marsh USA Inc. 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
1215 Fourth Avenue, Suite 2300 AFFORDED BY THE POLICIES DESCRIBED HEREIN.
Seattle, WA 98161-1095
Attn: Kathy B. Harid 206 613-2625 Fax: 206 613-2516 COMPANIES AFFORDING COVERAGE
COMPANY
WLCI -QCC-GAW-05-06 cont 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
COMPANY
DENVER, CO 80202
C AMERICAN HOME ASSURANCE COMPANY
COMPANY
D
co ERAGE$4,' :' This l:oertl ow S u pBr� Bede&A"`q 'rep it,goed certificate pollcy,o irlOdl noted
: 14
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 (MM/DDNY)
POLICY EXPIRATION
DATE (MMIDDNY)
LIMITS
A
GENERAL
LIABILITY
GL6051488
04/01/05
1 GENERAL AGOREGi% 1E 2,000,000
X
PRODUCTS - COMP /OP AGG
$ 2,000,000
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE I F�vl JOCCUR
7777
PERSONAL & ADV INJURY
$ 1,000,000
EACH OCCURRENCE
$ 1,000,000
OWNER'S & CONTRACTOR'S PROT
FIRE DAMAGE (Any one fire)—
_$_1,000,000
MED EXP An one person)
$ 5,000
A
A
AUTOMOBILE
LIABILITY
ANY AUTO
CA2053350 (AIDS)
CA2053349 (TX)
04/01/05
04/01/05
04/01/06
04/01/06
COMBINED SINGLE LIMIT
$ 2,000,000
X
A
ALL OWNED AUTOS
SCHEDULED AUTOS
CA2053348 (VA)
04/01/05
04/01/06
BODILY INJURY
(Per person)
$
X
'(
BODILY INJURY
(Per accident)
$
HIRED AUTOS
NON-OWNED AUTOS
� X
SELF-INSURED FOR
PROPERTY DAMAGE
$
'WTO PHYSICAL DAMAGE
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN AUTO ONLY:
ANY AUTO
EACH ACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
HUMBRELLA FORM
$
OTHER THAN UMBRELLA FORM
A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
WC5899586 (AOS)
04/01/05
04/01/06
IAI _7_071`im
X I TO WRY S1
LIMITS 1 ER
WC5899585 (CA)
04,101!05
04/01,106
EL EACH ACCIDENT
1,000,000
A
A
THE PROPRIETOR/ INCL
OFFICERS ARE: PARTNERS/EXECLITIVE EXCL
WC5899588 (ND OH WI WV WY)
WC5899597 (OR)
04/01/05
04/01/05
04/01/06
04/01/06
EL DISEASE-POLICY LIMIT
I$ 1,000,000
EL DISEASE-EACH EMPLOYEE
1 $ 1,000,000
HER
C
Excess Workers' Compensation
WC5899589 (WA)
04/01/05
04/01/06
SIR Each Accident/Employee $1,000,000
Excess of SIR Shown Above $1,000,000
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS
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,
CANCELLATION
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 2 DAYS WRITTEN NOTICE TO THE
CITY OF COPPELL
ENGINEERING DEPARTMENT
CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
255 PARKWAY BOULEVARD
LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE
COPPELL, TX 75019
ISSUER OF THIS CERTIFICATE.
MARSH USA INC.
BY: Cheryll L. Koch
'MMItlicip VALID AS OF: 03/29/05
• � � i i i i
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 0
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
4 1 •
This endorsement modes insurance provided under the following:
Name Of Additional Insured Persons Or Organization(s)
As Shown on Certificate of Insurance.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Section 11 — Who Is An Insured is amended to in-
clude as an additional insured the person(s) or organi-
zations) shown in the Schedule, but only with respect
to liability for "bodily injury", "property damage' or
"personal and advertising injury" caused, in whale or
in part" by your acts or omissions or the acts or on-"Es-
sions of those acting on your behalf:
A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or
rented to you.