Fiberlight-CS090904T H [ • C l T Y - O F
RIGHT -OF -WAY MAINTENANCE USE FEE
Ordinance No. 2001 -944, Sec. 6 -14 -3.
Registration Form for Service Provider
Registration expires March 1 of every other year after the calendar year in which the first
registration occurs. If registration is not renewed by the expiration date, after written notice
from the City, the facilities of the service provider will be deemed to have been legally abandoned.
Service Provider (include any business name
operated under for past 5 years) q- �-
operates under or has
PUC Certificate Number (for certificated telecommunications providers) #31459; S POCA #60736
City of Coppell License Ordinance No.
ContactNames/Numbers Russell Lytle, Operations Manager
817- 795 -4000 (Direct); 817 - 795 -6233 (Fax)
817- 538 -8532 (Cell)
Contractor(s) Name Future Telecom
Contact Information Don Riggs 972 - 329 -6400
Emergency Contact Judd Carothers 817-613-1825
Liability Insurance Carrier Marsh USA, Inc.
(Sec. 6 -14 -3 (h))
Attach proof of coverage
Plans of Record provided to Engineering Dept. for existing facilities Y N
For proposed facilities. Y •Y' N
Forward registration form and fee to Engineering Dept., City of Coppell,
255 Parkway Blvd., Coppell TX 75019
For office use only
Registration Fee of $250.00 paid l_l D� Receipt No. j) ,P2 4 6 6
DATE (M
9 /10 /
ACORd CERTIFICATE OF LIABILITY INSURANCE 0M/DD/YYYY)
L/ 09/10/2009
PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION
Marsh USA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
701 Market Street, Suite 1100 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
St. Louis, MO 63101 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Attn: stlouis.certrequest @marsh.com 212 - 948 -0811
800679 - STND -GAWUP -09/10 INSURERS AFFORDING COVERAGE NAIC #
INSURED FiberLight, LLC INSURER A: St. Paul Fire 81 Marine Ins Co 24767
3655 Brookside Parkway, Suite 550 INSURER B: N/A N/A
Alpharetta, GA 30022 INSURERC:
INSURER D:
INSURER E:
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
POLICY EFFECTIVE
DATE(MMIODNYYY)
POLICY EXPIRATION
DATE(MMIDDNYYY)
LIMITS
A
X
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE � OCCUR
TE01202096
05/09/2009
05/09/2010
EACH OCCURRENCE
1,000,000
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 1,000,000
MED EXP (Any one person)
$ 10,000
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GENERAL AGGREGATE LIMIT APPLIES PER
POLICY JECT X LOC
PRODUCTS - COMP /OP AG
2,000,000
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIREDAUTOS
NON -OWNED AUTOS
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
GARAGE
LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY: AGG
$
$
EXCESS / UMBRELLA LIABILITY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $
EACH OCCURRENCE
$
AGGREGATE
$
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N
OFFICER /MEMBER EXCLUDED?
(M PROVISandatory in NH) If yes, describe under
SPECIAL IONS below
WC STATU- O R
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYE
$
E.L. DISEASE - POLICY LIMIT
$
OTHER
VLJVti —i— VT LKUVKJLMLKI/or rL 1ALr'KVVI,IVNJ
City of Coppell is included as additional insured on the above General Liability Policy only as required by written contract and as respects to building access
license agreement. XCU is silent under the GL policy.
CERTIFICATE HOLDER CHI - 002657774 -01 CANCELLATION
City of Coppell
255 Parkway Blvd
Coppell, TX 75019
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
IUy{yPOQREP
N THE INSURER, ITS AGENTS OR REPRESENTATIVES.
Of MarsPF1EU RESENTATIVE
C.
Mary Radaszewski
ML WMLO AD U 1995 -2009 ACORD CORPORATION. All Rights Reserved
The ACORD name and logo are registered marks of ACORD
1 ,109] il_1 `►
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.
Acord 25
ADDITIONAL INFORMATION CHI - 002657774 -01 0DATE(M00°9m)
PRODUCER
Marsh USA Inc.
701 Market Street, Suite 1100
St. Louis, MO 63101
Attn: stlouis.certrequest@marsh.com 212 - 948 -0811
800679 -ST N D -GAW U P -09/ 10
INSURED
FiberLight, LLC
3655 Brookside Parkway, Suite 550
Alpharetta, GA 30022
TEXT
E &O /Network & Information Security Liability
Carrier: St. Paul Fire & Marine Insurance Company
Effective dates: 05/09/2009 to 05/09/2010
Policy Limit: $1,000,000/$1,000,000
Deductible: $50,000
CERTIFICATE HOLDER
City of Coppell
255 Parkway Blvd
Coppell, TX 75019
INSURERS AFFORDING COVERAGE
INSURER F:
INSURER G:
INSURER H:
INSURERI:
Of uni e r C. Inoue f
Of an nc.
Mary Radaszewski
NAIC #
8
p r$
p
N
i _-
BY__ -- - ------ --
FIBERLIGHT, LLC
3655 BROOKSIDE PARKWAY
SUITE 550
ALPHARETTA, GA 30022
PH (678) 366 -0027
Memo: Registration Fee
PAY
ToTHETwo Hundred Fifty and 00/100 Dollars
ORDER
OF:
City of Coppell
WACHOVIA BANK, N.& 12005
ACH R/T 061000227
64- 22/610 DATE
Check Number: 12005 Sep 9, 2009
AMOUNT
$ 250.00
TWO SIGNATURES REQUIRED OVER $6,000.00
L
AUTHORZF_U SIGNATURE
1150 1 200 SIIS 1:0 6 X000 2 2 71: 20000 L 3 9 L 58 3 4115
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Employee includes a leased worker, other
than a leased temporary worker.
Leased worker means any person who:
• is hired from an employee leasing firm
under a contract or agreement between the
hirer and that firm; and
• is performing duties related to the conduct
of the hirer's business.
Volunteer worker means any person who:
• isn't an employee or a leased temporary
worker;
• donates his or her work; and
• isn't paid a fee, salary, or other
compensation for that work.
Employee leasing firm means any person or
organization that hires out workers to others.
It includes any:
• employment agency, contractor, or service;
. labor leasing firm; or
• temporary help service.
Leased temporary worker means a leased
worker who is hired to:
• temporarily take the place of a permanent
employee on leave; or
• meet seasonal or short -term workload
conditions.
Controlled by means:
• owned, rented, leased, occupied, borrowed,
or used by;
• in the care custody, or control of; or
• being physically controlled for any
purpose by.
Health care professional services includes:
• any dental, medical, mental, nursing,
surgical, x-ray, or other health care
professional service, including any advice,
instruction, food, or beverage provided
with such service;
• the dispensing of drugs or medical or
dental supplies and appliances; and
• the handling or treatment of corpses,
including autopsies, organ donations, and
other postmortem procedures.
We explain the term premises damage in the
Each event limit section.
Real estate managers. Your real estate
managers are protected persons only for
their management of premises that you rent,
lease, or borrow from others, or own. They
may be persons or organizations. 0
But we won't apply this Real estate
managers section to your employees.
Instead, we'll apply the Employees and
volunteer workers section to them.
Landlords. Any landlord, lessor, manager, or
owner of a premises rented or leased to
you is a protected person only for the
ownership, maintenance, or use of that
premises while you rent or lease it.
However, no landlord, lessor, manager, or
owner is a protected person for injury or
damage that results from any of the
following work while being done by or for
such landlord, lessor, manager, or owner:
• Structural changes.
• New construction work.
• Demolition work.
But we won't apply this Landlords section to
your real estate managers. instead, we'll
apply the Real estate managers section, or
the Employees and volunteer workers
section, whichever section is applicable, to
them.
Equipment lessors. Any lessor or owner of
equipment rented or leased to you is a
protected person only for your operation,
maintenance, or use of that equipment while
you rent or lease It.
However, no equipment lessor or owner is a
protected person for injury or damage that
results from its sole negligence.
Persons or organizations for your work as
required by written contract. Any person or
organization that:
• is not otherwise a protected person under
this agreement; and
• you specifically agree in a written contract
to add as an additional protected person
under this agreement;
is a protected person, but only for covered
bodily injury or property damage that results
from your work.
However, no such person or organization is
a protected person for bodily injury or
property damage that results from their sole
negligence.
47150 Rev. 7-01
Page 8 of 28 a 2001 The St. Paul Travelers Companies, Inc. All Rights Reserved
•
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Also, such person or organization is a
protected person only for the lesser of:
• the limits of coverage required by the
written contract; or
g • the limits of coverage available under this
agreement.
Additional protected person may also be
called an additional insured in that written
contract.
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We explain the term your work in the
Products and completed work total limit
section.
Vendors of your products. Any vendor of
your products is a protected person for
covered bodily injury or property damage
that results from your products, but only if:
• you specifically agree in a written contract
to add the vendor as an additional
protected person under this agreement;
• this agreement provides coverage for
those products; and
• those products are sold or distributed in
the normal course of the vendor's
business.
However, no vendor from whom you've
acquired your products is a protected
person.
Nor is any vendor a protected person for
bodily injury or property damage that results
from:
• any express warranty which is made by
the vendor and you haven't authorized;
• any change made in the condition of any
of your products by the vendor;
• the repackaging of your products other
than when the products are unpacked for
demonstration, inspection, testing, or
replacement of parts ordered by you or
the manufacturer, and later repackaged in
their original containers;
• any failure of the vendor to perform
normal or agreed upon servicing of your
products which the vendor has sold or
distributed;
• the demonstration, installation, or servicing
of your products, which is done away
from the vendor's premises; or
• your products which have been labeled or
relabeled, or used as an ingredient, part,
or container in, on, or for anything else,
by or for the vendor.
Servicing includes any adjustment, assembly,
disposal, inspection, repair or test.
We explain the term your products in the
Products and completed work total limit
section.
Operators of registered mobile equipment All
operators of registered mobile equipment are
protected persons for covered bodily injury
or property damage that results from their
driving of such equipment on a public street
or road with your permission.
Any person or organization legally
responsible for the driving conduct of those
operators is also a protected person for
such bodily Injury or property damage. But
only if there's no valid and collectible other
insurance available to cover its liability for
the operators.
However, no operator or any other person or
organization is a protected person for:
• bodily injury to a fellow employee of the
person driving the equipment; or
• property damage to property controlled by
you or the employer of an operator who
is a protected person.
Registered mobile equipment means mobile
equipment that's registered in your name
under a motor vehicle registration law.
We explain the terms:
• controlled by in the Employees and
volunteer workers section,
• mobile equipment in the Mobile equipment
exclusion; and
• other insurance in the Other Insurance
section.
Unnamed subsidiaries. Any of your
subsidiaries, other than a partnership, joint
venture, or limited liability company, that
isn't shown in the Introduction as a named
insured is a protected person if you own
more than 50% of it on the beginning date
of this agreement.
However, no unnamed subsidiary is a
protected person for:
• bodily injury or property damage that
happened before you own more than 50%
of it;
• personal injury or advertising injury that
results from an offense that's committed
before you own more than 50% of it; or
• injury or damage that's covered by other
similar general liability insurance.
47150 Rev. 7 -01 Insuring Agreement
0 2001 The St. Paul Travelers Companies, Inc. All Rights Reserved Page 9 of 26
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