WA9701-CS070420CERTIFICATE O F INSURANCE Certificate # 46849 3541 ISSUE DA004/20/07 M/DDNY)
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.
COMPANIES AFFORDING COVERAGE
Ohio Casualty Insurance Company
Texas Mutual Insurance Company
THIS IS TO CERTIFY THAT 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,
cvrri I ICInAIC nnln r nAInITInNR 0P RI I(tH POI ICIER I IMITR SHOWN MAY HAVF RFFN RFDUCFD BY PAID CLAIMS.
COMPANY A
LETTER
COMPANY B
LETTER
INSURED
COMPANY `.
LETTER
J T Dersner, Inc.
2101 E. Shady Grove
COMPANY D
LETTER
Irving, TX 75060
COMPANY E
LETTER
CO
LTR
Ohio Casualty Insurance Company
Texas Mutual Insurance Company
THIS IS TO CERTIFY THAT 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,
cvrri I ICInAIC nnln r nAInITInNR 0P RI I(tH POI ICIER I IMITR SHOWN MAY HAVF RFFN RFDUCFD BY PAID CLAIMS.
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES /SPECIAL ITEMS Project - Uenton I ap Koaa i o lncn water Line tAlnme unve (X
Bethel Road), Project No. WA- 97 -01. Bod No. 0- 0805 -02 - Certificate holder and Birkhoff Hendrocks & Conway, LLP are added as additional insured to General Liability
and Auto Liability. Waiver of Subrogation is added in favor of same to include Workers Compensation.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City Of Coppell EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
P.O. Box 9478 MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
Coppell, TX 75019 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
7
C
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM /DD/YY)
POLICY EXPIRATION
DATE (MM /DD/YY)
LIMITS
'
A
GENERAL LIABILITY
GENERAL AGGREGATE
$ 2,000,000
X COMMERCIAL GENERAL LIABILITY
BKO 3285665
12105/06
12/05/07
PRODUCTS - COMP /OPAGG.
$ 2,000,000
CLAIMS MADE FX ]OCCUR
PERSONAL& ADV. INJURY
$ 1,000,000
..
t =.
OWNERS & CONTRACTORS' PROT.
EACH OCCURRENCE
$ 1,000,000
a
X Blanket Additional Insure
FIRE DAMAGE (Anyone lire
$ 100,000
MED. EXPENSE (Any one person)
$ 10,000
ZPA
Blanket Waiver Of Subrogation
A
AUTOMOBILE LIABILITY
COMBINED SINGLE
$ 1,000,000;:
`
X ANY AUTO
BAO 53285665
12/05/06
12/05/07
LIMIT
BODILY INJURY
$'
X ALL OWNED AUTOS
X SCHEDULED AUTOS
(Per person)
§
X HIRED AUTOS
BODILY INJURY
$
-
X NON -OWNED AUTOS
(Per accident)
.-.
GARAGE LIABILITY
PROPERTY DAMAGE
$
-
A
EXCESS LIABILITY
EACH OCCURRENCE
$ 2,000,000
X UMBRELLA FORM
USO 53285661
12/05/06
12/05/07
AGGREGATE
$ 2,000,000
OTHER THAN UMBRELLA FORM
a ?-
B
X STATUTORY LIMI
WORKER'S COMPENSATION
EACH ACCIDENT
$ 1,000,000
TSF0001144211
04/23/07
04123/08
DISEASE- POLICY LIMIT
$ 1, 000,000
AND
EMPLOYERS' LIABILITY
1,000,000
DISEASE -EACH EMPLOYEE
$
OTHER
Limit $425,000 w/ $1,000,000
Aggregate
Rented /Leased Equipment
BK053285665
12/05/06
12105/07
$500 deductible
Actual Cash Value
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES /SPECIAL ITEMS Project - Uenton I ap Koaa i o lncn water Line tAlnme unve (X
Bethel Road), Project No. WA- 97 -01. Bod No. 0- 0805 -02 - Certificate holder and Birkhoff Hendrocks & Conway, LLP are added as additional insured to General Liability
and Auto Liability. Waiver of Subrogation is added in favor of same to include Workers Compensation.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City Of Coppell EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
P.O. Box 9478 MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
Coppell, TX 75019 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
7
CERTIFICATE O F INSURANCE Certificate # 46708 3541 ISSUE DAT 04/20/07/YY)
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.
COMPANIES AFFORDING COVERAGE
Ohio Casualty Insurance Company
Texas Mutual Insurance Company
THIS IS TO CERTIFY THAT 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 HI1REIN IS SUBJECT TO ALL THE TERMS,
CV/`I I ICInnIC AKIn cnnlnlTlnnlC nF RI It'.W Pnl Ir'IFC I IMITC CHnWN MAY HAVF RFFN RFni Ir.pn RY PAID CI AIMS_
COMPANY A
LETTER
COMPANY B
INSURED
LETTER
J T Dersner, In
COMPANY `+
2101 E. Shad y Grove
LETTER
Irving, TX 75060
COMPANY D
$ 2, 000, 000
X
LETTER
COMPANY E
X COMMERCIAL GENERAL LIABILITY B
BKO 3285665 1
LETTER
Ohio Casualty Insurance Company
Texas Mutual Insurance Company
THIS IS TO CERTIFY THAT 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 HI1REIN IS SUBJECT TO ALL THE TERMS,
CV/`I I ICInnIC AKIn cnnlnlTlnnlC nF RI It'.W Pnl Ir'IFC I IMITC CHnWN MAY HAVF RFFN RFni Ir.pn RY PAID CI AIMS_
x Blanket Additional Insure FIRE DAMAGE ( Any one fire $ 100
=; Blanket Waiver Of Subrociation ME ID. EXPENSE (Any one person $ 10 000
... A AUTOMOBILE LIABILITY COMBINED SINGLE
X ANY AUTO BAO 53285665 12/05/06 12/05/07 LIMIT $ 1,000,000 a
1 �
X ALL OWNED AUTOS BODILY INJURY"
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS BODILY INJURY
` X NON -OWNED AUTOS (Per accident) $
GARAGE LIABILITY
PROPERTY DAMAGE $
A EXCESS LIABILITY EACH OCCURRENCE I s 2, 000,000
X UMBRELLA FORM USO 53285661 12/05/06 12/05/07 AG REGATE $ 2, 000,000
OTHER THAN UMBRELLA FORM
X STATUTORY LIMITS
B WORKER'S COMPENSATION?
AND TSF0001144211 04123107 04!23/08 EA HACCIDENT $ 1 000,000
EMPLOYERS' LIABILITY DISEASE- POLICY LIMIT $ 1 000 000
DISEASE -EACH EMPLOYEE I s 1 000 000
A OTHER
Rented /Leased Equipment BK053285665 12!05/06 12/05!07 Limit $425,000 wl $1,000,000 Aggregate
$500 deductible
g ,.
` Actual Cash Value
DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES /SPECIAL ITEMS Re: Operations of Insured
Certificate Holder is included as additional insured as respects General Liability and Auto Liability.
City of Coppell
255 Parkway Blvd.
Coppell, TX 75019
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE off%
r
CO P
POLICY NUMBER L
POLICY EFFECTIVE P
POLICY EXPIRATION
LIMITS
3 A GENERAL LIABILITY G
GE19ERAL AGGREGATE $
$ 2, 000, 000
X
PR DUCTS - COMP /OPAGG. $
$ 2, 000, 000
t
X COMMERCIAL GENERAL LIABILITY B
BKO 3285665 1
12/05106 1
12105/07 P
ti CLAIMS MADE I F X P
PE SONAL &ADV.INJURY $
$ 1, 000 , 000 y ,
OWNERS & CONTRACTORS' PROT. E
EA H OCCURRENCE $
$ 1, 000,000
DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES /SPECIAL ITEMS Re: Operations of Insured
Certificate Holder is included as additional insured as respects General Liability and Auto Liability.
City of Coppell
255 Parkway Blvd.
Coppell, TX 75019
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE off%
r