ST9302-CS020618nl;e,-,tu. 7n7s10
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~B12,~, CERTIFICATE OF LIABILITY INSURANCE o6jia%oa
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
HRH Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
5520 LB~7 Freewa S1Xth Floor
Y r HOLDER. THIS CERTIFlCATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Dallas, TX 75240
9 72 3 8 5- 9 92 2 INSURERS AFFORDING COVERAGE
---
INSURED ---
INSURER A: Employers Mutual_Casualt_y Company
Mel's Electric Service, Inc. INSURER
~,~
Tim Keierleber, Individual ~
~
INSURER i _
1810 S . Akard -
INSURER D
~ ~` ~~ ~~ ~ Y ___ __
Dallas, TX 75215 ~ _ _
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD fNDICATED. 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. __
NSR ~, ~ POLICY EFFECTIVE POLICY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY ~~ DATE MMA)D/YY LIMITS
A CENERALLIABILITY ~2D25359 O7/O1/O2 I O7/O1/O3 , EACH OCCURRENCE $1 OOO OOO_
~
X (COMMERCIAL GENERAL LIABILITY I
~ FIRE DAMAGE (Any One fire)
_ $3 O O , O O O
_ __._
CLAIMS MADE ~~ OCCUR ~' MED EXP (Any one person) $5 O O O
PERSONAL & ADV INJURY $1 O O O O O O
GENERAL AGGREGATE $2 OOO OOO
GEN'L AGGREGATE LIMRAPPLIES PER: ~; PRODUCTS •COMP/OP AGG $2 OOO OOO
~~~ _
LOC
POLICY JE 07 ~ ~
A . AUT OMOBILE LIABILITY 2E25359 I O7/O1/O2 07/01/03 COMBINED SINGLE LIMIT $1 OOO OOO
' ~ (Ea accident) r r
~ X ANY AUTO
ALL OWNED AUTOS ".. BODILY INJURY $
SCHEDULED AUTOS I (Per person)
~
X HIRED AUTOS ~ BODILY INJURY $
__
X I NON-OWNED AUTOS i ~ (Per accident)
r__. __ - -.-_
-.__-
_ ___ _._.__ _. ___.. _ ' PROPERTY DAMAGE
' $
. (Per accident)
GA RAGE LIABILITY '~ AUTO ONLY _ EA ACCIDENT $
ANV AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
A EXCESS LIABILIT 2J25359 O7/O1/O2 O7/O1/O3 EACH OCCURRENCE $lO OOO OO
Y.
' CLAIMS MADE
X OCCUR ~ ' _
AGGREGATE $1 O O O O O O
. .
$
DEDUCTIBLE ' _ -- $ -
~__ --
~
l, X RETENTION $1 O O O O
~ $
~
A WORKERS COMPENSATION AND
2H25359
O7/O1/O2
07/01/03 'WC STATU• OTH-
1 __~TORV LIMITS ER
~__ __
I EMPLOYERS' LIABILITY ~I I I
E.L. EACH ACCIDENT I
$5 O O, 0 0 0
E.L. DISEASE •EA EMPLOYEE $SOO, OOO
E.L. DISEASE • POLICY LIMIT $5 O O O O O
A OTHER Inland X25359 ',07/01/02 07/01/03 $100,000 Leased or
i Rented Equipment
ar
ne i$500 Deductible
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONSADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Project: Sandy Lake Road, Coppell
City of Coppell is additional insured with a waiver of subrogation
provided for the General Liability Policy.
ADD
City of Coppell
Engineering Department
255 Parkway Blvd.
Coppell TX 75019
SHOULD ANYOF TH E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TH E EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TOMAIL 3~ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TOTHE LEFT, BUT FAILURE TODOSO SHALL
IMPOSE NOOBLIGATION OR LIABILITY OF ANY IOND UPON TH E INSURER,ITS AGENTS OR
ACORD25-S(7/9~1 Of 2 #M82925 KNlI: V NVVI'1UVVr1rVnM11V1Y rJ00
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD25-S(7/9~2 of 2 #M82925