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UPN-CS180727T H E - C 1 T Y • O F •P A 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]. 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: 07 / 23 /2018 2. Name and Address of Service Provider (Include all names used within the last 5 years): Unite Private Networks, LLC 8111 LBJ Freeway, Suite 600 3. 4. Dallas, TX 75151 Is Provider certified by the Texas Public Utility Commission??t ( ) NO (0 YES if YES, Certificate Number � 08 / q Does Provider have a Valid License or Franchise Agreement with the City of Coppell? 00 NO ( ) YES if YES, Ordinance Number Date Approved 5. Provide Two Business Contacts (One must be within the Dallas/Fort Worth area): Tom Marvel Name Construction Manager Title 8111 LBJ Freeway, Suite 600, Dallas, TX 75151 Address (972)841- 5695 Telephone Rosalyn Beavers Name Right of Way Manager Title 7200 NW 86th Street, Suite M, Kansas City, MO 64153 Address (816) 368-9033 Telephone 6. Provide Two Emergency Contacts (Must be available AT ALL TIMES): Bill Tyler Name RVP of Construction Title 8111 LBJ Freeway, Suite 600, Dallas, TX 75151 Address (469)354-3214 Telephone (No Charge to the City) Tom Marvel Name Construction Manager Title 8111 LBJ Freeway, Suite 600, Dallas, TX 75151 Address (972)841-5695 Telephone (No Charge to the City) 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? 00 YES ( ) 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)? 0 YES ( ) NO if NO, Reason: Signature of Applicant (REGISTRATION ACCEPTED Charlene White, VP of Real Estate Printed Name FOR CITY USE ONLY 7/23/2018 Date ( ) REGISTRATION DENIED Comments: & 4, -712 711V — Si h'P rraature of Ci Representative Pnted ae " Date Provider shall indemnify and forever hold harmless against the City of Coppell each and every claim, demand, or cause of action that may be made or come against it by reason of or if any way arising out of the closure, blocking, excavating, cutting, tunneling, or other work by the provider under permit from the City, ifsuch permit is granted. AICORO® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YY (Y) 7/23/2018 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 Arthur J. Gallagher Risk Management Services, Inc. 1040 Crown Pointe Parkway Suite 700 Atlanta GA 30338 CONTACT NAME: Linda Smith PHGNE 67s-393-5228 aC No): 678-393-5240 E-MAIL ADDRESS: linda smith a' .com INSURERS AFFORDING COVERAGE NAIC q Y INSURER A: National Union Fire Insurance Company of Pittsburg19445 GL4611450 INSURED COX Communications, Inc. Unite Private Networks, LLC PO Box 105357 INSURER B: New Hampshire Insurance Company 23841 INSURER C: American Home Assurance Company 19380 INSURER D: Illinois National Insurance Company 23817 INSURER E : Atlanta GA 30348 INSURER F: rnVFRArFR CERTIFICATE NUMRFR! 1824759724 REVISION NUMBER: 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY M DDIYYYY MMIDD/Y� LIMITS A X COMMERCIAL GENERAL LIABILITY Y GL4611450 1/1/2018 1/1/2019 EACH OCCURRENCE $4,500,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 4,500,000 MED EXP (Any one person) $ Excluded X XS of $500,000 PERSONAL & ADV INJURY $ 4,500,000 X SELF INSURED RET GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 30,000,000 X POLICY E] JECTPRO F—]LOC PRODUCTS - COMP/OP AGG $6,000,000 $ OTHER: A A AUTOMOBILE LIABILITY CA7093399 AOS) CA70934(0 MA) 1/1/2018 1/1/2018 1/1/2019 1/1/2019 COMBINED SINGLE LIMIT $ 5,000,000 Ea accident BODILY INJURY (Per person) $ A X ANY AUTO CA70934(1 A) 1/1/2018 1/1/2019 OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR DED I I RETENTION $ B C D A` WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBEREXCLUDED7 N/A WC013779015((AOS) WC013779016(CA) WC013779017 M WG013779018 M�) 1/1/2018 1/1/2018 1/1/2018 1/1/2018 1/1/2019 1/1/2019 1/1/2019 1/1/2019 X STATUTE ERH E.L. EACH ACCIDENT $1,000,000 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below B B WORK COMP/EMPLOYERS LIAB WORK COMP/EMPLOYERS LIAB WC013779019(AZJIUKY/NC/NH/NJ/PA/U TNANT) 1/1/2018 1/1/2018 1/1/2019 1/1/2019 SEE ABOVE AMT OFINSURANCE SEE ABOVE AMT OFINSURANCE WC013779020 (MAIN D/0HfWA/ W11wY) DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of Coppell is Additional Insured as respects General Liability policy, pursuant to and subject to the policy's terms, definitions, conditions and exclusions. Coppell, Texas 265 Parkway Blvd. Coppell TX 75019 VAr4%,r_LLN I IVIY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ENDORSEMENT This endorsement, effective 12:01 A.M. 01/01/2018 forms a part of policy No. GL 461-14-50 issued to COX ENTERPRISES, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM, BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM MOTOR CARRIER COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM PRODUCTS -COMPLETED OPERATIONS LIABILITY COVERAGE FORM RAILROAD PROTECTIVE LIABILITY COVERAGE FORM TRUCKERS COVERAGE FORM EXTENSION SCHEDULE OF NAMED INSUREDS This policy provides coverage for the first Named Insured shown on the. declarations page and the following Named Insureds: COX COMMUNICATIONS, INC. 106936 (10/10) Includes copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 1 ENDORSEMENT This endorsement, effective 12:01 A.M. 01/01/2018 forms a part of policy No. CA 709 33 99 issued to COX ENTERPRISES, INC. by NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM, BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM MOTOR CARRIER COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM PRODUCTS -COMPLETED OPERATIONS LIABILITY COVERAGE FORM RAILROAD PROTECTIVE LIABILITY COVERAGE FORM TRUCKERS COVERAGE FORM EXTENSION SCHEDULE OF NAMED INSUREDS This policy provides coverage for the first Named Insured shown on the declarations page and the following Named Insureds: COX COMMUNICATIONS, INC. 106936 (10/10) Includes copyrighted material of Insurance Services Office, Inc. with it permission. Page 1 of 1