ST9905-CS040406 PRODUCER THiS CERTIFICATE iS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
Marsh USA Inc. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
The Fin&ncial Center POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
1215 Fourth Avenue, Suite 2300 AFFORDED SY THE POLICIES DESCRIBED HEREIN.
Seattle, WA 98161-1095
Attn: Kathy B. Harifi 206 613-2625 F~x: 206 613-2516 COMPANIES AFFORDING COVERAGE
COMPANY
QWLCI -QCC-GAW-04'05 KBH cg2026 A NATIONAL UNION TIRE INS CO OF PA
INSURED COMPANY
QWEST COMMUNICATIONS CORPORATION B INSURANCE COMPANY OF THE STATE OF PA
1801 CALIFORNIA STREET
SUITE 1150 COMPANY
DENVER, CO 80202 C AMERICAN HOME ASSURANCE COMPANY
COMPANY
D
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN iSSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD iNDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OS OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY RAVE SEEN REDUCED BY PAID CLAIMS.
CD TYPE OF INSURANCE POLICY NUMBER POUCY EFFECTIVE POLICY EXPIRATION UMITS
LTl: DATE (MM/DD/YY) DATE (MM/DD/YY)
A GENERAL LIABIETY GL~06219 04/01/04 04~1/05 G EN ERAL AG G REG P~TE $ 2,000,000
~ COMMERClAL G EN ERAL LIABILITY PRODUCTS-COM P/DP AGG $ 2,000,000
I
~ OCDDR PERSON~ · ADV,~URV $ ~,ooo,soo
CLAIMS
MADE
OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000
FIRE DAMAGE (Any one fire) $ 1
MED EXP (Any o~e persc~) $ 5,000
A AUTOMOBILE MABILITY AL5188917 (ADS) 04/01/04 04~1/05
COMBINED SINGLE LIMIT $ 2,000,000
A ~ ANYAL.rTo AL5188918 (LA, MN) 04/01/04 04/01/05
A ALL OWN ED AUTOS AL5188919 (MD, NY) 04/01/04 04/O1/05 BO DILY iNJURY
A SCHEDULED AUTOS AL5188920 (TX) 04/01/04 04~1/05 (Per person)
A ~ H[REDAUTOS A/5188921 (VA) 04/01/04 04~1/05 BODiLYiNJURY
~ NON-OWNED AUTOS (per accident)
X SELF-INSURED FOR pROPERTY DAMAGE
AUTO PHYSICAL DAMAGE
GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $
ANY AUTO OTHER TRAN AUTO ONLY:
C Excess Workers' Compen safl~ WC5212414 {WA) 04/01/04 04/01/05 SIR Each AccidenFEmployee $1,000,000
Excess ol SIR Shown Above $1,000,000
THE CITY OF COPPELL, TEXAS IS AN ADDITIONAL INSURED AS RESPECTS THEIR INTEREST IN THE OPERATIONS OF THE NAMED INSURED AS REQUIRED BY
WRITTEN REGARDING GENERAL LIABILITY COVERAGE.
CITY OF COPPELL DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 30 DAYS
ENGINEERING DEPARTMENT WRier EN NOTICE TO THE CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH
255 PARKWAY BOULEVARD NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER
CO PPE EL, TX 75019 AFFORDING COVERAGE, ~TS AGENTS OR REPRESENTATIVES, OR THE ISSUER OF THIS
BY: Meg Lucia ~ ~¢~-
Policy No: GL4806219 COMMERCIAL GENERAL LIABILITY
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
As shown on Certificate of Insurance.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule as an insured, but only with respect to liability arising out of your operations or )remises owned by or
rented to you.
THIS ENDORSEMENT MUST BE ATFACHED TO A CHANGE ENDORSEMENT WHEN ISSUED AFTER THE
POLICY IS WRITTEN.
Copyright, Insurance Services Office, Inc., 1984
CG 20 26 (Ed. 11 85) Printed in U.S.A.