MA FY 0405-CS050311 DATE (M M/DDPI'YY~)
ACORD. CERTIFICATE OF LIABILITY INSURANCE CSR J=
PAVEM- 1 03/11/05
PRODUCER 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 ~ELOW.
Jackson & Harmon Ins. Agency
510 N. Valley Mills Dr., #701
Waco TX 76710
Phone:254-772-6074 Fax:254-772-6864
NAIC#
38318
INSURED
Pavement Services Corporation
PO Box 1107
Euless TX 76039-1107
COVERAGES
IINSURERS AFFORDING COVERAGE
iNSURERA Republic Insurance Company
INSURERB Great American Ins. CO. of
INSURER C
INSURER D
INSURER E
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED 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
POLICY NUMBER
CLAIMS MADE ' Xj OCCUR
TXP5643065
A ! TCA5643066 03/10/05
B
GEN'L AGGREGATE LIMIT APPLIES PER
POL,OYI, i Loc
TOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
~EX~ESSIUMBRELLA LIABILITY
SBU5965766 03/10/05
WC5643067
I POLICY EFFECTIVE POLICY EXPIRATION / LIMITS
DATE (MM/DD/YY1 DATEIMMIDD/YY) EACH OCCURRENCE [ $ 1000000
03/10/05 03/10/06 !PREMISES (Eao¢¢ulence) $ 300000
MED EXP (Any one person) $ 10000
p~GEERSONAL & ADV IN J U RY $ 1000000
NERAL AGGREGATE $ 2000000
PRODUCTS COMP/OPAGG $ 2000000
$1000000
I Em~ Ben.
COMBINED SINGLE LIMIT
(B~oOal .(Ea accident)
ILY INJURY
(Per person)
BODILY INJURY
~er accident)
PROPERTY DAMAGE
(Per accident)
DEDUCTIBLE
[~i ~ETENTION $
10000
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPR~FTOR/PARTNER/EXE C UTIVE
OFFICER MEMBER EXCLUDED?
J If yes, describe under
SPECIAL PROVISIONS below
J OTHER
03/10/06
03/10/05
AUTO ONLY EA ACCIDENT
1000000
$
$
EA ACC
OTHER THAN
AUTO ONLY AGG i $
EACH OCCURRENCE $ 4000000
03/10/06 AGGREGATE $ 4000000
$
$
03/10/06 EL EACH ACCIDENT ~$ 1000000 EL DISEASE EAEMPLOYEE $ 1000000
EL DISEASE-POLICYLIMIT $1000000
~EScR~PT~N~F~PE~T~NS~L~CAT~NS~VEH~CLES~Ex~LUS~NSADDEDBYEND~R$EMENT~SPEC~ALPR~V~S~NS
Re: City of Coppell 04 St. Repairs, Job No. 05-267. Certificate holder is
named as additional insured on general liability. Waiver of Subrogation in
favor of certificate holder on general liability and workers compensation.
CERTIFICATEHOLDER CANCELLATION
CITCO-3
City of Coppell
ATTN: Garreth Campbell
255 Parkway Blvd.
Coppell TX 75019
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO~
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $O SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Rowland Jackson
ACORD 25 (2001108)
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(les} must be endorsed A statement
on this cedif~cate 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 m heu of such er~dorsement(s)
DISCLAIMER
'[ne Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issu,ng 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
ACORD 25