DR0501-CS060710ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID D
VORTCC
DATE(MM/DD/YYYY)
07/10/06
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Wm. W. George & Associates, Inc
10,000 N. Central, #1100
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
$ 100,000
CLAIMS MADE X❑ OCCUR
Dallas T7C 75231
Phone:214- 691 -5522 Fax:214 -691 -1537
INSURERS AFFORDING COVERAGE
NAIC#
INSURED
INSURE A: Amerisure Mutual Insurance Co.
GENERAL AGGREGATE
!INSURER B: American International Group
GE N'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
INSURER C:
POLICY X jFt2t LOC
Vortex Construction G.P., Inc.
9744 Brockbank Dr
Dallas TX 75220
INSURER D:
INSURER E:
l,V V Crtf1VGJ
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.
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LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE E DATE MWD EXPIRATION
GENERAL LIABILITY
LIMITS
EACH OCCURRENCE $ 1,000,000
A X X COMMERCIAL GENERAL LIABILITY CPP2038279 07/09/06 07/09/07
PREMISES (Ea occurence)
$ 100,000
CLAIMS MADE X❑ OCCUR
MED EXP (Any one person)
$ 5,000
P.O. Box 478
PERSONAL &ADV INJURY
$ 1,000,000
REPRESENTATIVES.
GENERAL AGGREGATE
s2,000,000
GE N'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
s2,000,000
POLICY X jFt2t LOC
Ben.
1,000,000
A
X
AUTOMOBILE
LIABILITY
ANY AUTO
CA2038278
07/09/06
07/09/07
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000
X
ALL OWNED AUTOS
BODILY INJURY
(Per person)
$
SCHEDULED AUTOS
HIRED AUTOS
BODILY INJURY
(Per accident)
$
NON -OWNED AUTOS
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY: AGG
$
ANY AUTO
$
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE
$ 5000000
AGGREGATE
$ 5000000
B
X OCCUR CLAIMSMADE
BE4803384
07/09/06
07/09/07
$
DEDUCTIBLE
$
X RETENTION $10
A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED.
WC2038277
07/09/06
07/09/07
X TORY LIMITS ER
E.L. E ACH ACCID
$ 100 0000
_
E.L. DISEASE - EA EMPLOYEE
$ 1 0004000
E.L. DISEASE - POLICY LIMIT
$ 1000000
H es, describe under
SPECIAL PROVISIONS below
OTHER
A
Equipment Floater
IM2038280
! 07/09/06
07/09/07
Max /Item
Amt Ins.
$50,000
$100,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Re: Wagon Wheel Park OUtfall Structure, Project #DR 05 -01. City of Coppell
is additional insured on general liability & auto liability as required by
written contract. Waiver of subrogation in favor of additional insured on
general liability, auto liability and workers compensation.
con,.r� I uun
ACORD 25 (2001/08)
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CITYCOP
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
City of Coppell
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Engineering Dept
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
P.O. Box 478
Coppell TX 75019
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
John S. Burruss
ACORD 25 (2001/08)
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.
ACORD 25 (2001108)