Northlake WE P10C-CS 961201 Certificate of Insurance
This is to Certify that .
SITE CONCRETE, lNG. LIBEP,~
P.O. BOX 140096 Name and MUTUAL
IRVING, TX 75014 ~ .... address of
Insured.
Is, at the issue date of this certificate, insured by the Company under the polic~-ies) listed below. The insurance afforded by the listed policy(ies) is subject to all their
terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this cerlificate may be
issued ......
EXP. DATE
*- CONTINUOUS
TYPE OF POLICY -" EXTENDED POLICY NUMBER LIMIT OF LIABILITY
~ POLICY TERtvl
WOR KE R S ; COVERAGE AFFORDED UNDER WC EMPLOYERS LIABILITY
i LAW OF THE FOLLO;VING STATES: .......
COMPENSATION 12/1/97 i WC7-191-419018-016 Bodily Iniury By Accident
i TX $1,000,000 Each
~ Accident
Bodily Injury By Disease
! S1,000.000 Policy
· Limit
Bodily Injury By Disease
S1,000,000 Each
....... . ...... Person._
G E N E PAL General Aggregate - Other than Products/Completed Operalions
LIABILITY
OCCURRENCE Products'Completed Operations Aggregate ....
._ CLAIMS MADE Bodily Injury and Property Dama.qe Li~tbilitv ..........
Per
; Occurrence
"Personal and Adverlising Injury ................
~E~Ro DATE Organization
Other Other
AUTOMOBILE Each Accident- Single Limit '
LIABILITY B.I. and P.D. Combined
OWNED Each Person
NON-OWNED Each Accident or Occurrence
HI R ED Each Accident or Occurrence
OTHER ...............
ADDITIONAL COMMENTS
JOB #96-16 TOWN CEN'I'I_,.'R DRIVE & 'fO~,.~ C~NTER. BO[.,"I .EVARI), COPPELL TF. XAS
' It the certificate expiration date is continuous or extended term. you will be notified if coverage is terminated or reduced before lhe certificate expiration date·
SPECIAL NOTICE-OHIO: ANY PERSC', WHO. W -H NTENT -3 DE==.At-.D OR K?;OWIX$ T-AT HE .S FA$1LITAT'%$ A =~.AUD AGAI%ST Aiq I:-;S[~=.E~, SJBM?S
A% APF_ICA-~C% OR =!LES A C-AIM CC'NTA!NII';G A FALSE C,R DECEP-IVE STATEMEN- ;S G~ILTM CF I%S.~=ANCE
NOTICE OF CANCELLATION: ¢,OT A~PL!CABLE UN_ESS A ',~M-~ER ~ DAYS IS ENTERED BELOWA BEFORE Liberty ~-'lutual Group
--E S-A-_=2 EX= RA-:,DN 3ATE THE COMPA%Y W L- ~IC, T OANCEL OR REDUCE THE NSU;:A%3E ACFCRCED
UNDE= -HE A3C, VE =C:_ 31--S UNTi~ AT LEAS- XX DAvS
CER'FCATE CITY OFTM~ MICHELLE BURNER
(,()I PE] .L
I-CL-~ER 255 PARKWAY BL\,'D. AUTHORIZED REPRESENTATIVE
(.',OPPF:LL, TX 75019 IRVING -PM (800) 443-2692 12,,'1/96
-- OFFICE PHONE NUMBER DATE ISSUED