Park West CC(15.1)-CS071030 (2)
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ACORQ" CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDIVYYY)
10/30/2007
PRODUCER Phone: 972-770-1600 Fax: 972-770-1699 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
McQueary Henry Bowles Troy LLP ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
12700 Park Central Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
17th Floor
Dallas TX 75251-0470
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: New Hampshire Insurance Co.
YMCA of Metropolitan Dallas
Attn: Stanley Smith INSURERB:Liberty J'1utual Insurance Co._~ /--.-.. -..-
601 N Akard ~!,>URER c: u - ~-- - ------ ---------- '-'--
Dallas TX 75201 INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED
NOTWITHSTANDING ANY REQUIREMENT,
CERTIFICATE MAY BE ISSUED OR MAY
TERMS, EXCLUSIONS AND CONDITIONS
IN~ ~~~~
A
GENERAL LIABILITY
~. COMMERCIAL GENERAL LIABILITY
L--L-J CLAIMS MADE IX] OCCUR
~
~
~'L AGGRE~E LIMIT APPLIES PER:
I I POLICY I I ~~PT n LOC
~TOMOBILE LIABILITY
fx- ANY AUTO
t. X ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
fA- NON.OWNED AUTOS
-
BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY NUMBER POLICY EFFECTIVE I POLICY EXPIRATION LIMITS
01LX04828783 11/1/2007 111/1/2008 EACH OCCURRENCE $1 000 000
I DAMAGE TO RENTED
I PREMISES lEa occurence\ $100 000
MED EXP (Anyone person) $ 5 000
PERSONAL & ADV INJURY $ 1 000 000
GENERAL AGGREGATE $ 2 000 000
PRODUCTS. COMP/OP AGG $ 1 000 000
A
01LX04828783
11/1/2007 11/1/2008
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
EACH OCCURRENCE
AGGREGATE
$
EA ACC $
$
$
$
AGG
~AGE LIABILITY
I ANY AUTO
AUTO ONLY. EA ACCI DENT
B
EXCESS/UMBRELLA LIABILITY
::=J OCCUR D CLAIMS MADE
~ DEDUCTIBLE
. I RETENTION $
WORKERS COMPENSATION ANO
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
I ~~~Sc~~~~5~rs~~NS below
i
i
OTHER THAN
AUTO ONLY:
$
$
$
WC2191435942017
11/1/2007
11/1/2008
X I T'1,~$ItJI~;" I IOJ~'
E.L. EACH ACCIDENT
E,L. DISEASE. EA EMPLOYEE
$ 500 000
$ 500, OO~L__~
$500 000
Physical Damage
Comprehensive
Collision
A
OTHER
Hired Car
01LX04828783
11/1/2007
11/1/2008
EL DISEASE. POLICY LIMIT
$60,000 Limit
$100 Deductible
$500 Deductible
DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
~dditional Insured form #81995 edition 05/03 applies to the General Liability policy.
he certificate holder shall be an additional insured in accordance with all the terms, conditions, and limitations of
he policy and then only with respect to liability caused by the negligent acts or omissions of the Named Insured
rontinued. . .
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
City Of Coppell BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE
300 Southwestern Blvd CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO
POBox 478 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
Coppell TX 75019 THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE ~ 4--r
ACORD 25 (2001/08)
@ ACORD CORPORATION 1988
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS I SPECIAL PROVISIONS
Waiver of subrogation form #WC420304A applies to the Workers Compensation policy.
Certificate Holder is provided Waiver of Subrogation per the above form on the Workers Compensation policy of insured,
but only to the extent that the limits and forms are required to satisfy the terms of a written contract.
IMPORT ANT
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 (2001/08)