Grandy's-CS03051494I3- 322 -9549
From: Ginette Lindsey At: Boley- Featherston Insurance FaxID: 940- 322 -9549 To: LARRY DAVIS, CITY INSPECTOR Date: 5/14/03 09:00 AM Page: 1 of
Fax
From: Ginette Lindsey To: LARRY DAVIS, CITY INSPECTOR
Pages: 3
Date: 5/14/03
Subject: KASSION CONSTRUCTION
Message:
Phone: (940) 723 -7111
Fax: (940) 322 -9549
Fax: (972) 304 -3570
Phone:
CERTIFICATE OF INSURANCE FOR:
GRANDY'S RESTAURANT PROJECT; 131 N. DENTON TAP RD., COPPELL, TEXAS
75019
THE PoL _IES OF II *JRANC.E LISTED BELOVb HAVE BEEN ISSUED TD THE INSURED NAMED ABO1.E FOP, THE POLICY PERIOD INDICPTED. (I TV'ITHSTANDING
PI I R-7LIIPEMEI IT TEEM OR O: NDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE I GSLED OR
Min PERTAIN THE No TRANCE 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.
iNbit
LTR
LTR
AIJIJ L
NSRD
NS
TYPE OF INSURANCE
POLICY NUMBER
DATE (MMIDDIYY)E
POLICY
DATE (MM/DDIYY)N
LIMITS
A
INSURER B Mount Vernon rise Ineurence Co
GENERAL
LIABILITY
CCMMERCIALGElEPALLIABILITY
CL420500393
01/03/03
01/03/04
EACH OCCURRENCE
1,000,000
VHMAbt I V Ht P� I tU
PFEMISE
50,000
X
CLAIMS MADE X 1 OCCUR
MED EXP (Anv one person)
$5,000
PERSONAL ADM INJLIRY
$1,000,000
GENERAL AGGREGATE
$2,000,000
3BJ'LARNREGATE LIMIT APPLIES PER
PRODUCTS CcMP /OPAGG
2,000,000
LIC Y PRO-
PO ECT LTC
Q
AUTOMOBILE
LIABILITY
,4 AUTO
ALL 0?/VNED AU To
SC HEDL�LED AUTOS
HIR ED ALTOS
NON- GVvNED AUTOS
72XAN213116
01/03/03
01/03/04
COMBINED 'SINGLE '.A' IT
(Ed as Client)
945,000
6
BODILY INJURY
(Per person)
X
BCE IL Y INJURr
(Per a -a dent)
PROFEPCr DAMAGE
(Per as:idenC
GARAGE
LIABILITY
AN ADTT
AUTO ONLY EAACCIDEN
TTHER THAN EA ACC
I$
AUTO ONLY .AGG
B
EXCESS /UMBRELLA LIABILITY
CUP2106097
01/31/03
01/31/04
EACH OCCLIRREN
5,000,000
VCCUR CLAIMS MADE
AGGREGATE
5,000,000
DEDUCTIBLE
RETENTION $10,000
X
D
WORKERS COMPENSATION AND
EMPLOYERS LIABILITY
AN r' PROPRIETOR/EAPTNERIEXECUTNE
OFF■CEP /MEmBEP E;CLLIDEno
If veo,tlescnbe ).ruder
GEE :IN_ PRO''NSIMNS I'f IU'N
TsF0001127155
02/01/03
02/01/04
WUSIAILA 'JI
TORY LIMITS ER
EL EACH ACCIDENT
1000000
E L. DISEASE EA EMPLOYEE
1000000
E L DISEASE PGLICr LIMIT
1000000
E
OTHER
BUILDERS RISK/
INLAND MARINE
BR58730376
01/04/03
01/04/04
$1000 DED $3,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
RE: GRANDY'S RESTAURANT PROJECT, 131 N. DENTON TAP ROAD, COPPELL, TX 75019
FAXED TO: CITY OF COPPELL 972- 304 -3570
CERTIFICATE OF LIABILITY INSURANCE OPID GI
ACORD KASSC -1
DATE (MM /DDNYYY)
05/14/03
PRODUCER
Boley Featherston Insurance
P O. Box 97513
Wichita Falls TX 76307 -7513
Phone: 940-723-7111 Fax:940- 322 -9549
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIC#
INSURED
Kassion Construction, Inc
201 Brothers Blvd
Red Oak TX 75154
INSURER Evanston Insurance Company
35378
INSURER B Mount Vernon rise Ineurence Co
INSURERC rational rise 6 Marina ins Co
20079
INSURER D Texas Mutual Ins Co
INSURER E Zurich Insurance Company
CITYCO 8
CITY OF COPPELL
ATTN: LARRY DAVIS,
CITY INSPECTOR
P.O. BOX 9478
COPPELL TX 75019
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
ITIV
From Ginette Lindsey At: Boley- Featherston Insurance FaxID: 940 322 -9549 To: LARRY DAVIS, CITY INSPECTOR Date: 5/14/03 09:00 AM Page: 2 of
ACORD 25 (2001/08)
ANCELLATION
From: Ginette Lindsey At: Boley- Featherston Insurance FaxID: 940- 322 -9549 To: LARRY DAVIS, CITY INSPECTOR Date: 5/14/03 09.00 AM Page: 3 of
ACORD 25 (2001/08)
I M PORTANT
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.