ST9301-CN071205
s-T 3 "'01
CERTIFICATE OF INSURANCE
Certificate # 46849
ISSUE DATE (MM/DD/YY)
3541 12/05/07
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
COMPANY A
LETTER
Ohio Casualty Insurance Company
INSURED
J T Dersner, Inc.
2251dlewild Rd.
Grand Prairie, TX 75051
COMPANY B
LETTER
Texas Mutual Insurance Company
COMPANY C
LETTER
COMPANY D
LETTER
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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DD/YY) DATE (MM/DD/YY)
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE [iJOCCUR
OWNERS & CONTRACTORS' PROT.
x Blanket Additional Insured
Blanket Waiver Of Subro atlon
AUTOMOBILE LIABILITY
BKW 53285665
12/05/07
GENERAL AGGREGATE
12/05/08 PRODUCTS-COM PlOP AGG.
PERSONAL & AfN. INJURY
GENERAL LIABILITY
USO 53285661
$
12/05/07 12/05/08
BODILY INJURY $
(Per person)
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
EACH OCCURRENCE
12/05/07
X ANY AUTO
X ALL OWNED AUTOS
X SCHEDULED AUTOS
X HIRED AUTOS
X NON-OWNED AUTOS
GARAGE LIABILITY
BAA 53285665
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION
AND
EMPLOYERS' LIABILITY
TSF0001144211
04/23/07
04/23/08
DISEASE-POLlCY LIMIT
DISEASE-EACH EMPLOYEE
OTHER
Rented/Leased Equipment
Owned Contractors Equipment
Per Schedule
DESCRIPTION OF OPERATIONS/LOCATlONS/VEHICLES/SPECIAL ITEMS Project - Denton Tap Road 161nch Water Line (Airline Drive &
Bethel Road), Project No. WA-97-01. Bod No. Q-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.
BM053285665
12/05/07
12/05/08
Limit $425,000 wI $1,500,000 Aggregate
$1,000 deductible
Actual Cash Value
City Of Coppell
P.O. Box 9478
Coppell, TX 75019
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL ~ 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
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