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MCI-CS170804T H 6 C I T Y • O F COFFELL PUBLIC RIGHTS-OF-WAY MANAGEMENT ORDINANCE REGISTRATION FORM Submit completed form to the Engineering Dept., Town Center, 265 Parkway Blvd., Coppell, TX, 75019 This registration form is required by Sec. 6-14-3 of the City of Coppell Code of Municipal Ordinances. It is to be renewed every other year by March 1. This document does not take the place of obtaining a Right -Of - Way Use Permit prior to performing any work in the public right-of-way. 1. Date of Submittal: / / 13 /--o-Z013 2. Name and Address of Service Provider (Include all names used within the last 5 years): 3. Is Provider certified by the Texas Public Utility Commission? () NO WYES if YES, Certificate Number 571oO 4. Does Provider have a Valid License or Franchise Agreement with the City of Coppell? NO () YES if YES, Ordinance Number Date Approved, 5. Provide Two Business Contacts (One must be within the Dallas/Fort Worth area): � eVP b tA e ,Role /Nnnte Nome 1 A S+(o C); r` y 0. Rd ?n/ 1 Jhn S-iIL 1. "lay1G �I �✓ Title II Title !'' —IIJU L-,erhr p�� i `It oti c f. crdyrr, j� . qu u N Address Address Telephone Telephone 6. Provide Two Emergency Contacts (Must be available ATALL TIMES): Nance _Lead Terl — Nucs Title you :rA1#/nw.j-,,,.1 ?I!k ?i—t; ;v_ TX Address Nance Ler. d a I I fc�- ��fa Title Lm -i .47L., T(A RfM ei 7f cL Ti( Address a114- AJ-1425�.12- G-70 -031a Telephone (No. Charge to the Coq) Telephone (No Cirorge to Nle Cil}) 7. Have the names, addresses, and contact information for all known contractors or subcontractors that will be working in the public right-of-way on behalf of the Provider been furnished to the City? (> ES ( ) NO if NO, Reason: 8. Has proof of insurance meeting the requirements of Sec. 6-14-3 BA(h) of the Public Rights -Of - Way Management Ordinance been furnished to the City (the City must be named as an additional insured on the policy by using endorsement CG 20 26 or broader)? (YES ( ) NO if NO, Reason: v gnature of Applicant Panted Name Date FOR CITY USE ONLY (,)REGISTRATION ACCEPTED ( ) REGISTRATION DENIED Comments: Signature of City Representative Printed Name Date Provider shall Indemnify and forever hold harmless against floe City of Coppell each and every claim, demand, or cause of action Neat may be made or come against It by reason of or if any way arising out of the closure, blocking, excavating, cutting, funneling, or other work by the provider tinder permit from the City, if such permit is granted. �°`# h® CERTIFICATE OF LIABILITY INSURANCE DAT07M 8120,/YYYY) 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(les) must have ADDITIONAL INSURED provisions or 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 Aon Risk Services Northeast, Inc. New York NY Office CONTACT NAME: (A/CNNo. Ext): (866) 283-7122 C. No : (800) 363-0105 199 Water Street New York NY 10038-3551 USA E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: National Union Fire Ins Co of Pittsburgh 19445 MCImetro Access Transmission Services Corp. 1095 Avenue of the Americas INSURER B: New Hampshire Ins Co 23841 INSURER C: American Home Assurance Co. 19380 New York NY 10036 USA INSURER D: Illinois National insurance co 23817 INSURER E: INSURER F: t,UVtKAUt:b GtKIII-IGAIt NUMULK: O/UUbt!)(U43S REVISION NIUMBFR! 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. Limits shown are as requested INSR LTR TYPEOFINSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY GL EACH OCCURRENCE $1,000,000 CLAIMS-MADEX❑ OCCUR D R TED $2,000,000 PREMISES Ea occurrence MED EXP (Any one person) $10,000 X GL Includes X,C,U PERSONAL BADV INJURY $1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000, 000 PRO - X POLICY [:] JECT LOC PRODUCTS - COMP/OP AGG $2,000,000 OTHER: A AUTOMOBILE LIABILITY CA 286-73-91 AOS 06/30/2017 06/30/2018 COMBINED SINGLE LIMIT Ea accident) $1,000,000 BODILY INJURY( Per person) A X ANY AUTO CA 286-73-92 06/30/2017 06/30/2018 A OWNED SCHEDULED AUTOS ONLYAUTOS HIREDAUTOS NON -OWNED ONLY AUTOS ONLY MA CA 286-73-93 VA 06/30/2017 06/30/2018 BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident UMBRELLA LIABOCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION B B WORKERS COMEMPLOYERS' LIABILITY ION AND Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? NIA WC063724385 AOS �WC063724388 06 30 2017 06/30/2017 06 30 2018 06/30/2018 )( STATUTE EORH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below MN E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Named Insured Includes: MCImetro Access Transmission Services Corp, dba verizon Access Transmission Services. RE: To Work in the Public Right-of-way. City of Coppell is included as Additional Insured with respect to the General Liability policy. CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. _ City of Coppell AUTHORIZED REPRESENTATIVE Attn: Scott Lata 255 E. Parkway Blvd. Coppell TX 75019 USA �f_ p t�f%`�� (/'a 'JL ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000027366 LOC #: '4 ADDITIONAL REMARKS SCHEDULE Page _ of AGENCY Aon Risk Services Northeast, Inc. NAMEDINSURED MCImetro Access Transmission POLICY NUMBER See Certificate Number: 570067579433 CARRIER See certificate Number: 570067579433 NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: GL 5196564 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Any person or organization whom you become obligated to include as an additional insured as a result of any contract or agreement you have entered Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 ❑