UPN-CS200219T H. E. C f 7 Y.❑ F
COPPELL
�6-1-
�
PUBLIC RIGHTS-OF-WAY MANAGEMENT ORDINANCE.
REGISTRATION FORM
Submit completed. form to the. Engineering Dept., Town Center, 265 Pavllway Blvd., Copp ell, TX; 75019
v .,aih
This. registration form. is required by Sec 614-3 of the City of Copp ell Code: of Municipal Ordinances. It is
to be renewed every other }year by lYlarclr 1. This document floes not take the place of obtaining a Right-nf
Way rise Permit prior to performing any work in .the public right-of-way.
1. Date of Submittal:. 2 1 3 1 2020
2. Name and Address of Service Provider (Include all names used within the last 5 years):
Unite Private Neworks, LLC
3.
4.
8.1.11 L$J Freeway,..5uite:600.
Dallas, TX 75151
Is Provider certified by the.Texas Public Utility Commission?
(} NO (x) YES
if YES, Certificate Number 60879
Does Provider have a Valid ]License or Franchise Ag.re ment w ith the City of Coppell?
W NO (} YES if YES, Ordinance Number
Date Approved 1 l
Provide Two Business Contacts (One must be within the Dallas/Fort Worth area):
Tom Marvel
Name.
Construction Manager
Tirle
811 l L8J Freewa . Suite 600. Dallas TX 75151
Address
(972) 841-5595
Telephone
Rosalyn Beavers
Mang
Right.of Way Manager
Title
7200 NW 86..th Street, Suite M, Kansas City, MO 6415.3
Address
(816)68-9033
Teleplfone
6. Provide Two Emergency Contacts (Must be available ATALL TIMES):
Bill Tyler
Name
Regional Vice President
Title
Tom Marvel
Name
Construction Mana er - Texas
Thk
8I 1 I LBJ Freeway, Suite 600, Dallas, TX 75151 8111 LBJ Freeway, Suite 600, Dallas, TX 75151
Address Address
(464) 354-3214 (972) 841-5695
Telephone (No Charge to the Ctry) Telephone (No Charge to the Oty)
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?
CX) YES ( ) NO if NO, Reason:
8. Has proof of insurance meeting the requirements of See. 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)?
(x) YES ( ) NO if NO, Reason:
I
Charlene White, VP of Real Estate 2/3/2020
Signature of Applicant Printed Name date
FOR CITY USE ONLY
()j REGISTRATION ACCEPTED
Comments:
( ) REGISTRATION DENIED
AA 4P• S•ze
Signature of Ci Representative Printed Name Date
Provider shall indemnify and forever hold harmless against the City of Coppel[ 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, if such permit is granted.
ACr'C]RD®DATE
CERTIFICATE OF LIABILITY INSURANCE
1 MOWYYYYI
CERTIFICATE MAYBE ISSUES] .OR MAY PERTAIN. THE INSURANCE AFFORDED. BY THE POLICIES DESCRIBED HEREIN IS .SUBJECT TO ALL THE TERMS;
12/24/2019
THIS CERTIFICATE 1S 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 COVERAGEAFFORDED BY THE POLICIES
BELOW.. THIS CERTIFICATE OF INSURANCE DOES AOT 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 have ADDITIONAL INSURED previsions 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 end.orsetnent(s).
PRODUCER
Arthur,). Gallagher Risk Management Services, lhc.
NAME .Linda Smith
_
PHONE �mm_,_ _w ..W_.• _� FAx
1050..Crown Pain#e Pkwy, SUIfs 600
G9tc ilo_gXtl;(Pic No): , 678-393.5228 I -5240
mm
E- d"I ss; lfrida__,smith@zijg.com
Atlanta GA 30338
—T_ INSURER(SAFFDRDING CDVERAGE w.w�i NAIC#
i PRDDUCTS-COMPIDPAGG 404,400
:561
INSURER A: National Union Fire InsuranC@.__ C_ omparl pf 171tt5(?Ur 19445
_ ______„•,_,_,,,_„ �„ ____,_,,._...�,_ ,,.. ,_. „_,_..,,�-.
.INSURED
Cox: Communications, Inc:
.INSURER B: New.Ham shire Insurance Com an 23841
- - - — L - -- p
INSUR ER c: American Home Assurance Company ' 1938
..._.......�.._....�..._�. _
UnitePrivate networks, LLC
INSURER D, 1111nDI . National lnsuranae.goi pony _ _ i 23817
PC Bax 105357
Atlanta GA 30348
INSURER E : i
INSURER F:
I [Per accidence` ---
COVERAGES CERTIFICATE NUMSER: 7AAA351312 F@EVISlf)N N1INIRFR•
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED. BELOW: HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
IND]CATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT MOTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUES] .OR MAY PERTAIN. THE INSURANCE AFFORDED. BY THE POLICIES DESCRIBED HEREIN IS .SUBJECT TO ALL THE TERMS;
EXCLusioNs AND.CONDITtONS OF SUCH POLICIES.. LIMITS SHOWN MAY HAVE SEEN REDi1_CED BY PAID CLAIMS.
INSR! --�_--__._--;AOnL SUBR - l' - _-....�.---
LTR TYPE ❑FINSURANCE. , PDLICY.NUMBEI7
__ I MMItID YY ENMIDDIYYYY ? LIMITS
W j POLICY EFF POLICYExP.
A I }( i COMMERCIAL GENERAL LIABILITY Y GL8862525
1/1/2020 4/1/2021 1
LEACH OCCURRENCE 54,500,000
I._...�.._w.�
CLAIMS [
DAMAGE TO RENTED)^.-._...._-.-...._...._,
-MADE OCCUR
I PREMISES (taaavrrence _� $4,500,0Q0
~.�M -Ww
xS
X . flf$500.000 T—_
i MED EXP. ArL one erson
� � y p } i S Excluded
I X i i
SELF INSURED RET
PERSONALE. ADV INJURY S4,500,000 m� w
ry1
GEN'L AGGREGATE LIMIT APPLIES PER
x•-: r� I.
GENERAAGGREGATE^�
,pp,p
L 5 3DO04.
....._�..-
PRO-
PDLICY I�I JECT LRC
i PRDDUCTS-COMPIDPAGG 404,400
:561
OTHER:
A AUTOMOBILELIABILITY CA663113.1
; 1/1/2020 ! 1/112421 '• CDMBINEi151NGLE.LIMIT 510;004,004.
Ea acciiieni
A ?
ANY AUTO i CA6631132
11.1T2020 '11112421 i -.._.......-...-.m-....._.T...__
3 BODILY ENJ6kY {Per person} $
OWNED SCHEDULED i !
AUTOS ONLY AUTOS
i BODILY tNJURi (Peraocidenl) S. T .T
x HIREDx l NON -OWNED j
AJTOS•ONLY ! AUTOS
t PROPERTY DAMAGE 5
�._... i ONLY i
J
I [Per accidence` ---
i 1
• UMBRELLA LIAR' S ,
I OCCUR � S
I s i EACH DCCUR3�ENCE ! $
HI _
.ExCESS.LTAB
f CLAIMS-MADEI S
_�—DE-0—TJ
AGGREGATE 5
s RETENTION 5
B 'WORKERS COMPENSATION i WCO208Q8738
'AND
1/9/2020 ( 1/712021 X PER ? IOTH- 1
= STATUTE
C EMPLOYERS' LIABILITY I
Y!N 1 WCO20608739
❑ 1ANYPROPRIETORJPARTNERIEXECUTIVE WO020808740
IOFFICE R?MEM13EREXCLUDE D7 � � I N! A I � �
,„_,.,,
! 117/2024 1111202.1'
1/9/2020 11'1,7021 E L EACH ACCIDENT s 51,000,044
�•-:-�----------------------
:(Mandatory In NH) i
If.yes, do crlbe.uilder
'r
E, L. DISEASE -EA EMPLOYEEi 5.1,0_00,000 -w
iDEes3RIPTION OF OPERATIONS below
E,L, piSFASE- POLICY LIMITS 1,000,000
B. t V417RK COMPIEMPLOYERS LIAR. f € WCO20608741
11112020 ! 1/112027 ii SEE ABOVE AMT OF INSURANCE
B WORK COMPIEMPLOYERS.LIAB:WCO20608742
s I
I i
SEE '1!'112020 j 1111202'1 i OF INSURANCE
I I i
..ESCRIPTION OF 0PERATIONS 1 LOCATIONS I VEHiC3,ES [ACORD 101, Addltional:Remarks Schedule, may. he attached if more spa ca. is required]
City of Coppell.Is Additional Insured as respects General Liability policy, pursuant to and sUbjectto1he poky's terms, definitions, coriditions.and exclusions.
CERTIFICATE HOLDER CANrFl I ATInN
Q 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25.(2016103) The ACORD name. and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES. BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
C:oppell, Texas
265 Parkway Blvd.
Coppell TX 75019
AUTH IZEDREPRESENTATIVE
Q 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, 0 110 1/2020 forms -6 part of
policy No. GL6852525 issued to COX ENTERPRISES, INC.
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA
This endorsement modifies insurance.proWded 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.
1069-36(10110) :Includes copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 1
ENDORSEMENT
This endorsement, effective 12:01 A. M. 0 110 1/2020
forms a part of policy No: CA6631131
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. DA MAG E.COVERAGE FORM
GARAGE COVERAGE. FORM
LIQUOR LIABILITY COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
DINNERS AND .CONTRACTORS PROTECTIVE. LIABILITY COVERAGE FORM
PRODUCTS -COMPLE'T'ED OPERATIONS LIABILITY COVERAGE FORM
RAILROAD PROTECTIVE LIABILITY COVERAGE FORM
TRUCKERS COVERAGE FORM
.EXTENSION SCHEDULE OFNAMED INSUREDS
This policy.provides coverage for the first Named Insured shown on the declarations page and the
following Named Insureds:
COX COMMUNICATIONS, INC.
105935 �10Y10] Includes. copyrighted material.of Insurance Services Office,. Inc. with it permission.
Page 1 of 1