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Qwest-CS130821 ® DATE(MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE ilia....------ 08/21/2013 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. 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). PRODUCER CONTACT Marsh USA Inc. NAME: PHONE FAX CA License#0437153 (A/C.No.Ext): (A/C,No): 1301 5th Avenue,Suite 1900 E-MAIL Seattle,WA 98101-2682 ADDRESS: Attn:Seattle.certrequest @marsh.com I Fax:212-948-4326 INSURER(S)AFFORDING COVERAGE NAIC# 113913-CTL-GAW-13-14 cont none INSURER A:Greenwich Insurance Company 22322 INSURED XL Insurance America,Inc. 24554 CenturyLink,Inc.and all subsidiaries, INSURER e including but not limited to: Qwest Communications INSURER C:XL Specialty Insurance Company 37885 International Inc.;Sawis,Inc.;and Embarq Corporation INSURER D: 931 14th Street,10th Floor Denver,CO 80202 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002239566-17 REVISION NUMBER:19 THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR_ INSR,WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY X RGD500033301 09/01/2013 09/01/2014 EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY^ J 7 LOC $ A AUTOMOBILE LIABILITY RAD500033401-AOS 09/01/2013 09/01/2014 COMBINED SINGLE LIMIT 2,000,000 _(Ea accident) $ A X ANY AUTO RAD500033501-MA 09/01/2013 09/01/2014 BODILY INJURY(Per person) $ X ALL OWNED SCHEDULED Auto Physical Damage-Self Insured BODILY INJURY(Per accident) $ X HI/R DS AUTOS x NOON-O NED PeOr accident) TY DAMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION RWD500032901 AOS 09/01/2013 09/01/2014 X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE © RWR500033001 WI 09/01/2013 09/01/2014 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C XS Workers'Compensation/EL RWE500033101-WA 09/01/2013 09/01/2014 Excess of$1,000,000 SIR $1,000,000 C XS Workers'Compensation/EL RWE500033201 OH 09/01/2013 09/01/2014 Excess of$1,000,000 SIR $1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) THE CITY OF COPPELL,TEXAS IS AN ADDITIONAL INSURED PER THE GENERAL LIABILITY BLANKET ADDITIONAL INSURED ENDORSEMENT AS RESPECTS THEIR INTEREST IN THE OPERATIONS OF THE NAMED INSURED AS REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION CITY OF COPPELL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ENGINEERING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 255 PARKWAY BOULEVARD ACCORDANCE WITH THE POLICY PROVISIONS. COPPELL,TX 75019 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Cheryll L.Koch ( ,tz- __, ,KjaL_ I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD