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Fiberlight-CS211006T M �E C 1 TY •w O F 0 p P.E.1"L L io PUBLIC IUGHTS�OF-WAV MANAGEMENT ORDMA,NC'E REGISTRATION FORM Subin it 0mpleted. i[arm to the El ngin'ecring Dept., Town Center,165 .I'arkivay Blvd,, Coppell, TX, 75019 This registration far'nr is required by Noe. 6.44-3 of `the City of Coppcl/ Code �i_f'mill] iciprrl Urdirrrr"Cay. 11 is to be reneived elwlrl y other.} ear l y .Afarch 1. 77tis documeld Moes not take lire place of obtaining a Right -qf- lf'gjy (Ise Permit mit prior to peiforining any "wi-A in the public ril lr� of=ai�rey: 1. llute of Submittal- 07 1 1:5 i '2021 2. Name amici Address of Service Provider (Include- all mares use -t pithin the last 5,y ears)> F1 berLigh(,.LLC, 3.[]ti0 Sit mmit Placa, Suite 10.0. Alphuctta, CSA :0009 3. Is Provider certified .by the.'I'Mm Public Utility Commission? if YES, Certificate Nitmber SI3CO.A #60736 4. Does Provider luve a. Valid Litcnse or Fr,1nehise Agrecinent with thc City of Coppell? {)j NO ( ) VES (/'YES, Ordinance Number:.._: Date A:I)la, ovecl Provide Two Business Contm!ts (One must be vithin the DallrrXIFort Worth area); Ricky Rigg", = ", Steve (3m -drier NTrr+ri• � Name owner- Futu:'e'relecom TWO 1800 tlruton rd Mesquite TX. ;1 dilretcs 972.329-600 7'elep&rirre owner -Gardner rel coni nnunictltimis Dde 555 Town Etist Mesquite 'I'x :1rlrlrcfi3 972-329-9991 Tc'oli phenje 6. 11'rovide Two Emergency Contacts (Must be available AT AL1. 774fES): Tommy m Lineberger Name _ Field Service Technician ''171h, 320 Westway PI, Arlington,'FX 7 018 .4ddress 817-521.3898 Telephone phone (Na C hiorge In they City) Mike liitsche Nelow Project Manager T hle .,Idrlrrsti-- 214-755-6741 Tekphene ovf) i*lmry ry rhe Civ) 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? {) YES { ) NO if Nd, Rcasoir: 8. Has Proof of insurance meeting the requirements of Sec. 6-14-3 F3.4{1} of the Public Rights-Of- Way ights-OfWay Management Ordinance been furnished to the City (the City, inust be nanted a.v all additional insured on the poliq, bj, recur► endomentent CG 20.26 or broader)? (� Y LS ) NO if NO, Reason: S gnature tof Applicant 1'rinted Name I ate FOR CITY USE ONLY { dfitECISTRATION ACCEPTED ( ) RLGISTRA` ION DENIED Comments: T Signature of City FRepre%entalive Printed Name I?ute Provider shall intlemnify� and forever lottot harpith s against (he [. ►gip of C i►ppell each and every rlahn, de maid, or cause of action rhat ►tuy he made or come against it by reaso►t of or if wtv ovgp arising ow of the closure. blocking, exiw}whig, cartuig, iuutieling, or orlter ivork hY the pr{rl' der untler perntit from the Qv, il'suc•h permit is,cianfeil. r,fi—to. i an i noo rimpoi if -_4 ACORD.u. CERTIFICATE OF LIABILITY INSURANCEDATEIPAMIMaIYYYYI 6/3012021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER= THIS CERTFICATE. DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, EXTEND OR ALTER THE COVE=RAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETW45N THE ISSUING' INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, fMPpRTANT; If the eBrtifieate.halder. is an AOI]ITIONAL INSUREL7, the pvllcy�iesj must have ADI7ITII]1VAL INSURE❑ provisions or be.endnrsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies. may require an andarsament. A statDmont on this certificate does not confer any rights to the certificate holder In Ileu of.such endorsm-wnt[s]. PRODUCER N OIT Dana Johnson USI ICISttrarlC .$eFHiCBS, LLC CL ..-._.-._.-_._.,._.............. ........... -..._..........- .... . -----._ PHONE FAx' - "- 3 [Arc Nn,_r�xtl_ 800 $49-09$2.. [AIC. Naj. 610-537-1929.. 1 Concourse Pkwy NE _. _..._...._....._....._..= E=mA'li Da'na.Johnson@u.si.com ApaR:~ss:..:... hnsonus 700 -. ,.........._t-�.:.com ..�.-.-.:... W- -_. ..__.._.. INSGRERiS 11FF[7RI]INR CCIVRAG� W _ NAIC.N m Atlanta, GA 30328 __ INSURER A : Hanover Ainarican Insurance COmOny 30064 _�.-_..�_ ..........__..... .... ..:.....�...�._.......:....:...............::.._.._.-........................._...... W.......__._...� .._ _ .......m._....._._ ... INSURED INSURER 0 W Hanover Insurancc:Company 22282___._ Fiberli.ght, LLC _ _� __..._ w.._...w_ _.._r__......_..._._. INSURER c ; MaSSaChUgetts Bay Insurance Company 22306 3000 Summit Place .............. ...........:.............. _.............._ .__._.........._._W_.._.m._._._........-.....-._._.... ......... :.... ,.. Suite 200 INsuRr_R.o Alpharetta, GA 30009 INSURER E : . _ .. . If yes, doscribe undar INS U R EFi F �uvtrcr�tae5 ►.:crt � If ,l+H � c. naiawoe=rc: os�v�.��u�v rvuiv3a�at, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE. FOR THE POLICY PERIOD INDICATED; NOTWITHSTANL(NO ANY RVOUIRGMENT, TERM OR CONDITION OF .ANY CONTRACTOR OTHER oocu mr WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR.MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED. HEREIN IS .SUaJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUci1�5.. LIMITS SHOWN MAY HAVE [SEEN REDUCED 13Y PAID CLAIMS- _.-_ _-....__.._._ ._._.....___-.._..._._.._._---._..._...___.-_.___ _ ` ._ _____ __.._ __ w__._... _ _ _ _..-...._ _�.._ m.__.__... _.._...._-._._.. _ �TiRR 3 OaL,SUeR; POLICY EF r . POLICY EXP . . TYPE OF INSURANCE 111J51; `:l^n►I]. I POLICY NUMBER [MINfPAfYYYY} [MM10ofYYYYj LjfAjTS A xi CflMMERCIAI GiNCRAL LFAIIILi7Y ZZAH3005.1301 D.7101/2021'; 0710112022 EACIi OCCURRENCE S'E,OQ0,000 FRMItCS CsEaiiu e�w 51OQ 044 .3 -MADE _I ocrun g } r µ MEDarxPlA,y�,,�,I,auar,y $10,000 _-......... .._... _- ......:................ Pf_R2ONAL s Aov tNJI1RY. 51,000;004 GENT ArcRCGAT6.. LIMIT APPi.IrSPER µ c;> NLIiAtAc Gree w,7e 5214Q4�444 .._.-....__. 1 PRa, 7S-GOMf�OPnGf3 52,fl0ii3OQO ,— . x. I:QO PttDDl1G PQLIOY jr; rT I, -- _ _....._.. OTHER .'T.�........_.- L: [JM61NEDSlNGLE.LIMIT .........._-_.._..ww-._._..._...._..... C 's Aurantaul�E EIAnIS,ITY : AaAH28954401 710912421 0710.11202 {I@ iaonli . $1,000,040 I BODILY INJURY [Pn. pur::nrlj S ANY AUTO ............ j OWNEDSCHECDULEU AUTOSONLY AICIHI F30DILY INJU{2Y If'rr acurdenl} d .._..I _ i '�111R n NON i?WNE17 PROPERIY DAMAGE S ; AU pS ONLY x' RUTpS ONLY ; I .,L'_aracca{end..._..._..._.....__..._.. ,.__......-._.-...-......_....... .. _I S /� }�E uMRR[LLA LiAa _}( ti Luta ' UHAH30051R01 710/12021 071011202 6AGH DUCURRkNL'E s10,000,0�0_ --_-- EXCESS LIAR � �CLAWS•MAMk ` AGGREGATE _ Si 4,[04;004 _ of Dx Rf'iE.NTif}N $10004 :. S . ._ _... ,. .. WORKERS COMPENSATION ....... . . PER UThE- S7AT.UT[ ER AND ENIF LAYERS' LIABILITY Y I N i ANY. : s I E.S EACHACCOENT,.... S _PICFzRIMCMnFR PXCL[lI &)w N 1 A' i (Mandatory. in HFi) 1 F I It}gEASE � EA GMI'LUYfE. S . If yes, doscribe undar ........... ... ................... ESCRIPTION OF OPERATIONS bak m _ 0[Gr:ASC - POL0 LIMIT S. B ' Professiohai Liab LHAH30067701 7/0/12029 07/01/202 . $1,000,000 B =Cyber I LHAH30057701 710112021 071411202 $1,400,1900 DESCRIPTION OF OPE RATIO N51 LOCATIONS f VEHIGLES IAC0RD 101, Addidop.d 4pniarkr, 3ciinduI*, may ha;kuzjoad If mart) SPaca Ir-mquiradI City of COppell 255. Parkway Blvd Coppeli, TX 75019.0000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVIS10N6, AUTHORIZED REPRESENTATIVE (01988-2015 ACORD CORPORATION, All rights reserved. ACORD 26 (2016.103). 1 of 1 The ACORD name and logo. are registered marks of -ACORD 4632597117/1V132085839 JZGZP This page. has 1 eun.4cl) blank in Icul .ion lly. s T'1 DATE jMMIDOtYYYYI C" CERTIFICATE. OF LIABILITY INSURANCE &4 M7114 719.512421 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CE=RTIFICATE HOLDER. THIS CERTIFICATE voes NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND .OR. ALTER THE COVERAGE= AFFORDED 13Y 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 !lave ADDITIONAL INSURED provisions or.tie endorsed, 1f SUBROGATION IS WAIVED,' subject to the terms and conditions Of the policy, certain policies may require an ondarsomont. A statement an this cortificate dues riot confer. rights to the certificate holder II1 Ilou of such endorsement(s). PRODUCER NI/' CT LOoltton.Cainpanles,LLC PHONE ; r•Ax. 3557 t3rlarpark Dr,, Suite 740 RM 10iN0, Exl]:. RA7C,.No]:. IL .Houston, TX 77l]42anor�rss:-............ .-........ ....-..... MSURERIPi.A.FFOHDING COVERAGE .. .......... ... r AIC p INSURER A ; Indernn4 Insurance CA of {North Amuca 43575 ......... .................._..... _.....-........ ..._........ :....-.--....-.....-._.................- . 1 INSURED INSURER e FISERLIGHT, LLC _......:.._-..._ .....-_.... 3000 SUMMIT PL STE 200 INSUAER.0 : ....... .... ....... . .. . . ALPHARETTA., GA 3606-2S24 INSURER .Q.: INSURER E rNSURL•RF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS ISTO CER'TIF'Y THAT THC.. POLICIES Of INSURANCE LISTED BELOW HAVE BECN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PEMOD INDICATED. NOTWITHSTANo1.NG ANY REOUIR8MCMT, 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 HERFIN IS SUBJECT TO ALL 111E TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLIC#ES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. INSRi.. ............ ...... AiIOL-SU9R;.... ... '• POLICY [fFr• POLiCY:EXP s. LTR v TYPE OF INSURRSJCE S POLICY NUMOER MM1gwyYYY MMIaD Y YV S LIMITS ' ;COMMERCIAL GENERAL LiAOIL1TY ? EACH OCCURRENCE. $ .-._.; .. -, , I �ni�iiCO'C: Y6 PENTFri i ,� CLAIMS MADE j OCCUR IED orCuirPnG4) PIIEMISES -' � MED.E-XP {Airy on© Iyarsaa] $ s OEHSONAI, h ADV IN.IURY S { f ..- ': GCN'L. ArGnn ma LIMIT APPOL5 PER i GENERA!. AGGRCGATE . �..... ......... ...... . PC]LICY; PRO• {'ROgUC l'$ - CtiJAM1PfOP ACSG. $: _.._-----`-–`-OTFIErt'. ...._. 1 MBF D C,O . NE SINSiLI: LIMIT �.S. AUTOM 081LE LIABILITY BODILY INJURY111or parson] ANYAViQ i.._............._....... ALL OWN ED SCHEDULED INA)RY (N}n a ccKle ii) 5 AUTOS AUTOS [P[Oi'EF Y AiY] NON -OWNED i i i qr. f}sr rI�AI}... . A.DL _ . - ... ...� . HIRFO AUTOS i. _A AUTO$ € ? . $ —�3 BM6RELLA LIAR � EAC,Ii OCCURREN0E S �.-. SICCUR I i EXCESS IJAI3 1 l • I Gl,AIMS-MADE � A[iGI�L"GA,f _ s i E Y '• REI ENTION $ DEO VVOR K C R 8 COM PEN SATION X i PCH AND EMPLOYERS' LIA9iLITY Y 1 N _ . 7lITI�T...:.. _ , f R• ..... . ]ANS' PFiOF?RICTOR7PAf;TNE1t1�7sF:GLIiIVE ! E L.._LACIIA"3RFNT A ANY PizbvniiLlOR GXC:LL ERIE N 1 A i C081074Q7 101112UJU s '10!112027 1lMandniory In NF1j : E.L DISE A,E • EA CMf'L[7YEE $ 1 X4-000 If yyus, describe urKiCr E -L: DISEASE • POLICY '.IlE:S{;RIPTipN QFQPGRATICINS heffriY 'I ""^"""'""`•'-"-- i 1 4 f 11E5CRIPTION Of OPERATIONS ] LOCATIONS 1 VEHICLE5 IACURD 101, Addlllanal Ranmrkt Schl,ifulo, may Up al0o ed.It mom 9P;kco In mitilred] CERTIFICATE!�gLPER . - - ... CANCELLATION 1 SHOULD ANY OF.THC ADOVC.DE•SCPIDFD POLICIES BE CANCELI,E1) 6FFORt THE EXPIRATION DATE THEREOF.. NOTICE WILL BE DELIVERED IN ACCDRDANCD WITH THE POLICY PROVISIONS, AMIORIZQ4 REPRESENTATIVE CITY OF COPPELL PALL, TX BLVD CO CpPPELL, TX 7501,9 Q +M -M4 ACORD .CORI'{3HATlOIV. All rights reserved. ACORD 26 (2016103) The ACORD. name and logo are registered marks of ACORD