CF-Cozby Library-CS 940215 Certificate of Insurance ~
THiS CER] IFIOATE IS ISSUED AS A MATTER OF INFORMATION ONi Y AND CONFERS NO RIGHTS UPON YOU THE (;ERT!FI( ATE HOLDEk THiS CERTIFICATE IS NOT AN INSURANCE
POLICY AND DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PCLIO[FS LISTED eel OW I
This is to Certify that
I DIVERSIFIED CONSTRUCTION SERVICES, INC. | Name ard
17110 N. DALLAS PKWY SUITE 240 ~ address of
DALLAS, TX 75248 Insured.
I I
LIBERTY,
MUTUAL
Is, at the issue date of this certificate, insured by the Company under the policy(les) listed below. The insurance afforded by the listed policy(les) is subject to all their
terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may
be issued. ~
TYPE OF POLICY
WORKERS
COMPENSATION
GENERAL LIABILITY
[] OCCURRENCE
[] CLAIMS MADE
AUTOMOBILE LIABILITY
[] OWNED
[] NON OWNED
[] HIRED
OTHER
EXP. DATE
01/01/95
LIMff OF LIABILITY
01/01/95
RETRO DATE
POLICY NUMBER
WC2-141-037776-014
COVERAGE AFFORDED UNDER WC
LAW OF THE FOLLOWING STATES:
~ TB1-141-037776-034
01/01/95
IL, FL, AZ, TX
EMPLOYERS LIABILITY
Bodily Iniu~ By Accident
500,000 Each
Accident
Bodily Injury By Disease
Policy
Lirnil
Bodily Injury By Disease
500,000 Each
Person
General Aggregate - Other than Products/Completed Operations
Products/Completed Operations Aggregate
1,000,000
Bodity Injury and property Damage Uabifity
1,000,000 Occurrence
Personal and Adver'~sing injury
1,000,000 O~gamzatbn
AS2-141-037776-044 1,000,000
Each Accident - Single Umil
B.L and P.D. Combined
Each Person
Each Accident or Occurrence
Each Accident or Occurrence
ADDITIONALCOMMENTS
JOB: W.T. COZBY PUBLZC LIBRARY
177 HEARTZ ROAD
COPPELL, TX
PROJECT NO. 9113
*ADDITIONAL INSURED-SEE FOILM LG1005
SPECIAL NOTICE-OHIO: ANY PERSON WHO, WITH iNTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A
FRAUD AGAINST AN ~NSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE
STATEMENT tS GUILTY OF INSURANCE FRAUD.
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW) BEFORE THE STATED EXPIRATION DATE
~HE COMPANY WILL NOT CANCEL O~ REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL AT LEAST XXX DAYS
NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO:
CITY OE COP?ELL
~J~E 255 PARKWAY BLVD.
COPPELL, TX 75019
Liberty Mutual
[nsurahce Group
AUTHORIZED REP~ESENTATIV£
L~ · DATEISSUED
2/15/94 PEORIA, IL
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -- BLANKET
This endorsement modifies insurance provided under the followin!,~:
COMMERCIAL GENERAL LIAalLI~,~AGE PART
SECTION' II -- WHO iS AN INSURED is amended to inc/u~%all~lYj~ any oerson or or~'anization for whom
you have aizree,'J in writin§ to orovide LJal2ility insur'al~.~/,t~iqly_~tP~esDecI to Haedit7 ansme out of your
o:e~Iions or p~m~ses owned ~y or rented t~~ ~¢
insu~nce while such insu~nce is ~~s~f whe[~er [~e state of csve~se or lim~[s of msu~nce
CITY OF COPPELL, TX
1005