SS9901-CS071012
55 t:J9-o/
A CORD", CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDIYY)
10/12/2007
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
JOHN L. WORTHAM & SON, L.P. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. BOX 1388 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
HOUSTON, TEXAS 77251-1388 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
071555-659-23 ecb - tlinders INSURERS AFFORDING COVERAGE
INSURED INSURER A: Old Republic Insurance Company
CAN-FER CONSTRUCTION CO. AEGIS/Assoc. Electric & Gas Ins Serv
11031 GRISSOM LANE INSURER B:
DALLAS, TX 75229 INSURER C:
INSURER D:
I INSURER E:
COVERAGES
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.
II~~: TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE P~~~J' EXPIRATION LIMITS
A ~NERAL LIABILITY MWZY57602 10/10/2007 08/01/2008 EACH OCCURRENCE $ 1,000,000
~ =rMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anv one flrel $ 1,000,000
----' CLAIMS MADE [{] OCCUR MED EXP (Anv one Derson) $ NOT APPLICABLE
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
7l'L AGGREnE LIMIT AnS PER: PRODUCTS - COM PlOP AGG $ 2,000,000
./ POLICY p,rgT LOC
A ~TOMOBILE LIABILITY MWTB19927 10/10/2007 08/01/2008 COMBINED SINGLE LIMIT
$ 3,000,000
ANY AUTO (Ea accident)
1 ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
-
L HIRED AUTOS BODILY INJURY
$
-.:!... NON-OWNED AUTOS (Per accident)
---< PROPERTY DAMAGE $
(Per accident)
~RAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B EXCESS LIABILITY X2059A1A07 RETRO DATE 8/1/2002 10/10/2007 08/01/2008 EACH OCCURRENCE $ 5,000,000
r:rOCCUR [2] CLAIMS MADE AGGREGATE $ 5,000,000
$
=1 DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION AND MWC11530300 10/10/2007 08/01/2008 ./ I T~~J~J,\I.;, I IOJ~- $
EMPLOYERS' LIABILITY 1,000,000
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
OTHER
DESCRIPTION OF OPERATlONSlLOCATlONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
RE: DEFOREST ROAD LIFT STATION IMPROVEMENTSIDEFOREST & SANDY LAKE WASTEWATER LIFT STATIONS PROJECT #SS 99-01.
SEE ATTACHED/REVERSE
I
CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION (BELOW & SEE REVERSEI
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION 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 SO
CITY OF COPPELL SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
225 PARKWAY BLVD. THE ISSUER, ITS AGENTS OR REPRESENTATIVES.
COPPELL, TX 75019 'tl;l. R.ES~NTATIV:U.t t.1
I
ACORD 25-5 (7/97) " @ ACORD CORPORATION 1988
Cert. # 071555-659-23
CITY OF COPPELL
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 WAI VED, 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 Insura nce 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.
CANCELLATION NOTICE
The CANCELLATION NOTICE on the CERTIFICATE OF INSURANCE is amended to include the
following additional wording: The Insurance Company may cancel the described policy(ies) by mailing
or delivering ten (10) days written notice of cancellation to the Certificate Holder for:
(1) Non Payment of premium or (2) any other circumstance permitted by state law or policy conditions.
GENERAL LIABILITY AND AUTO LIABILITY POLICIES INCLUDE CERTIFICATE HOLDER AS AN ADDITIONAL INSURED WHEN
REQUIRED BY WRITTEN CONTRACT BUT ONLY AS RESPECTS LIABILITY ARISING OUT OF NAMED INSURED'S WORK FOR
ADDITIONAL INSURED.
GENERAL LIABILITY, AUTOMOBILE LIABILITY AND WORKERS' COMPENSATION POLICIES INCLUDE WAIVER OF SUBROGATION I~
FAVOR OF CERTIFICATE HOLDER WHEN REQUIRED BY WRITTEN CONTRACT BUT IN NO EVENT SHALL SUCH COVE RATE
EXCEED THE LIMITS, TERMS OR CONDITIONS OF THE POLICY.
ACORD 25-8 (7/97)