SS9901-CS080719
ACORQM CERTIFICATE OF LIABILITY INSURANCE I DATE IMM/DDIYY}
07/19/2008
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.
071555-1126-19 jea - Iwright INSURERS AFFORDING COVERAGE
INSURED INSURER A: Old Republic Insurance Company
CAN-FER CONSTRUCTION CO. INSURER B: AEGIS/Assoc. Electric & Gas Ins Serv
11031 GRISSOM LANE
DALLAS, TX 75229 INSURER C:
INSURER 0:
I INSURER E:
ss '\4-0 I
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.
I~~~ TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
A ~NERAL LIABILITY MWZY57984 08/01/2008 08/01/2009 EACIl OCCURRENCE $ 3,000,000
tI COMMERCIAL GENERAL LIABILITY FIRE DAMAGE IAnv one firel $ 1,000,000
1 CLAIMS MADE ~ OCCUR MEDEXPIAnvonenArsonl $ NOT APPLICABLE
- PERSONAL & ADV INJURY $ 3,000,000
- GENERAL AGGREGATE $ 3 000,000
~'L AGGREAE LIMIT APnS PER: PRODUCTS - COMP/OP AGG $ 3000,000
tI POLICY ~~R; LOC
A ~TOMOBILE LIABILITY MWTB20228 08/01/2008 08/01/2009
COMBINED SINGLE LIMIT 3,000,000
lEa accident) $
- ANY AUTO
~ ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
'--
~ HIRED AUTOS BODILY INJURY.
.1t- (Per accident) $
NON-OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
RGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B 5ESS LIABILITY X2059A1A08 RETRO DATE 8/1/2002 08/01/2008 08/01/2009 EACH OCCURRENCE $ 5,000,000
OCCUR 0 CLAIMS MADE AGGREGATE $ 5,000,000
$
==i DEDUCTIBLE $
RETENTION $ $
A WORKERSCOMPENSATlONAND MWCl1564900 08/01/2008 08/01/2009 tI WC STATU--1 IOJ~- .1..________ ..--
EMPLOYERS' lIABllIW
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATlONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
RE: DEFOREST ROAD LIFT STATION IMPROVEMENTS/DEFOREST & SANDY LAKE WASTEWATER LIFT STATIONS PROJECT #SS 99-01.
SEE ATTACHED/REVERSE
CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION (SEE BELOW & PAGE 2)
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 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
ANY KIND UPON THE ISSUER, ITS AGENTS OR REPRESENTATIVES.
CITY OF COPPELL
225 PARKWAY BLVD. 'd:lw7. RIrE~NTATW1k /..1
COPPELL, TX 75019
I ~ -- "
ACORD 25-S (7/97) Page 1 of 2 , ACORD CORPORATION 1988
COVERAGES
Cert. # 071555-1126-19
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 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.
CANCELLATION NOTICE
The CANCELLATION NOTICE on the CERTIFICATE OF INSURANCE is amended to include the following wording: The
Insurance Companies may cancel the described policy(ies) by mailing or delivering ten (10) days written notice of
cancellation to the Named Insured for: (1) Non Payment of premium or (2) any other circumstance permitted by state law or
policy conditions.
ADDITIONAL INSURED DISCLAIMER
Coverage for Additional Insureds can vary significantly from policy to policy and thus Additional Insured status does not
guarantee protection for all losses. Coverage is subject to actual policy terms and 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 IN FAVOR OF
CERTIFICATE HOLDER WHEN REQUIRED BY WRITTEN CONTRACT BUT IN NO EVENT SHALL SUCH COVERATE EXCEED THE LIMITS, TERMS
OR CONDITIONS OF THE POLICY.
ACORD 25-5 (7/97) Page 2 of 2