HomeMy WebLinkAboutContract 35311��''
�
,�
�=�7"a `r ��C�E�'��Y����l
,i, 1\.1 r4hit � a�i�. -r.-,—.�.�-__—_�
— _�i � i', �1(..���
CC��FS��TT AG12��iu�ENI'
- � FO�
TEIvII'ORARy US� OF FUBL�C PRO�'ERTY
STA'�`E C�F TEXAS
COUTITY O�' TA�RANT
THIS AGREFIVIENI' is made and en#ered i�rto by agd bet��een the City of Fo�fi V�orth, a
rt�unicipal corporariou of TaRant Cotu�ty, Texas, acting herein iiy and tiirough its �uly authoi�zed
' Building O�Ficial, hereina#�er re�'efred to as t�e "Czty" a€�t� ( TN6�CIG G(� � L. F�,
Acting bY and through zrs duly aut�lorized agei�t, f�`1 tC �-1 A� l_ ....� D H NSD N
T�erein�.fter referred to as "Gralrtee".
wrr�v�ss��:
For and in consideration oftl�e paymegt by Gran%e of charges set out be(ow and the true and
F4_�' ;-� nA ,� ^ �.,. ,
' iu.=u= �, T'.C','�„Z.;,C� vi �i�c iiiiiiud.� C0V8Ilr111i5 I'leTeFTI corttatne CY liereb
� �Y y grants to Gra�ltee
permission to temporarily encroac� upon, tzses alid oecupy poi�ion of th.e space t7nder, on ancl/or
above tIle s�treets, all�ys; sidewa�ks or otl�er public rights-of-u��y as fo�lotists: I, (oNE� Tµ=p� �-
TRA�c L►�,n��. Bt��,�l I�Ar�A� �p TAyco� A,s W�u.. AS SEcrror� aF c�-D� l/� L
SrDE�,J�t� _ q►�D Pi��YS�1G L�N� Ot�l Tf'.yt-C�R �T 5� O� SZ'�'� �SY."'E �rr��r�-��
The location and deserzpfion af said encroac�vnent �s rimore particuIaFlp described in Exhii,it "R"
attac�ed hereto, incorporated herein �nc� Fnade a part b�reof for atl p�t�-poses. .
2.
A11 use a�d occupancy of p�blic street; alleys, sidewaII�s or otltcr p�iblic ri�its-of-way under
�}zis a�reement shall be En strict co�np�iance with fhe Charte��, Ordi37ar�ces a�d �oc�es of tlle City
a�d �n accordance with the directions of the $uilding Q�eial and �he birector of Transpor'tation
aud Fi�biic �o�-ks of City, ` -
�, =- t : i
�� ,
s ,Sr�!'I 't iti' �r.,)�%,1' �
`-:i J '� 8 `�, j r.,: � o`•; u `'c; ���' ,!`, ��
�^ It 2" •�� � �'
r�i�,� S /,l �71',?
COUSEt�IT AC-RE€d�lE�lTior i empQrary vsa ofpu6Gc ra e doe �� ��� ���� L� [�"1�� ���L �' ;� �
P P �� , a .- , .
ti. ;,^' ( i' 1 f � i
i rl S�i
:'G'J,���� J_.;'�:�
�i
6
� 3.
�Jp�n expiration of this agreement and the �riviieges aranted hereunder, there s.hall be no
encroachment by Grai-�tee in, under, on or above t�e suciace oi the public rights-of-tivay invol�c�ed_
4.
Grantee agrees to pay in advance an er�croach�nent fee for the temporary privilege of
encraaching upon a portian of the �ptiblic rights-of-�,vay as described in Exhibi� "B"_ Said fee is
cafculated in the manner and amounts prescribed by the Building Code of tlie Ciiy of Fort Worth
lor temporary use or occupancy of pubizc properry, The estimated lotal amount oCsaid fee is=
��T �Z�AL = 18t� 5� x. 03 X ZZ� ��' I � I Sb
�Q,�Sa1G Lt� R��tr'�al. = Z83.Ss� x. 03 u ZLS = 8 1g �`'�
5�.,.�►���-. Qr��� = Z5Z s� �c . Ols x ZZS ��� 851
— -� To-rc,� =�Iy.91� �5�
�.
Grantee, at i�o expense to City, s(1a11 make proper provision foi- the relocation and/or
installation o�' any exi�ting or future traffic control devises or other improveme»ts afrected hy
such encroachment, use and occupaucy, including the securulg of approual and consent from the
appt�opriate agencies of the State and its political stibdivis�ons. In the evenf that ai�y itisfallation,
reinstal�ation, relocation or repair of any e�sting or futt�re traf�c contral device or impro�reinent
owned or coi�sfructed by or on behalf of the pub[ic or at public expense is made more costIy by
virtue of the esistence of such encroachment and iise, Grantee shatl pay t� City and additional
ainoi2nt equa( to such addi�ional cost as determined by Ciiy.
b.
The term of this agreement shaIl be for ZZ's days, from S/r°�, l �7 to �Z�� �o%�
Provid.ed, hou�ever, shouid the need for the encroachrnents granted hereunder �t any t�rne cease,
Grantee agrees to immediately notify City of such conditzon; and, upon receipt af such notice by
the �uilc�ing Ofrcial of the City of Fort �i%ortli, tllis agreer��ent sI�all termivate.
��
Tt is expressly u{iders�ood and agreed that tllis Consent A�-eement is for a temporary
encroacl�ment in, under, over and upon the public property as located and descr'tbed in Exhibit
2
C�DlSFt�IrAGREE1+1F1�tTrorTemporary useof p�olic pmpeityt.dec �
"B". This agreemeni sha11 not be construed as the granting of a permanent easement,
encroacllment or Iicense upon City's p1��lic streets, atleys, sidewalks, or othe�- rights-of-�,vay.
S.
City, �l�rough its duly authorized representative�, shall h�ve the ft�ll and unresfricted right �o
enter upon ��1 p�blic rights-of-�vay for the purpose of making inspections to determine
compl.iance with the ternls, covenants and co�ditions herei.n. In �he even# that any inspeciian
should reveal a breach of any teims, cot�enants or conditions herein, City shall gi��e Grantee
aotice of such breac[�. Sl�ottld such breach not be corrected by Grantee ��ithin twenty-four (24)
hours of receipt of the notice, or within such sfiot-�er period of �ime as deemed necessary by the
Burlding O�cial for the protection of public health or safety, City may terininate and cancel this
agreernenf.
9,
�Upon expiraiion or tei•mination of tliis agreement for any reason tiVhatsoever, Grautee shall, at
ii0 2<'i}�ci1Sc iv �iiy', CZSiOiZ iiiZ YiiuiiC ii�liiS-vi yJ3y �7.ilu a(�r�aCciti Si3�ri0iii21� SifLiCiuTcS i0 a
condition acceptable to the Director of Transportation and Public WorEcs or his dtily authorized
representative and in accordance �.vith fhen exis�ing City specifications, and Graniee shall remove
aI[ barricades, ec�uipment, supp(ies, maferials or o�hei• prope-rty fi-om said location. Grantee
fttrtIler covenants and ab -ees thaf for a period of one (I) year after the termination of this Consent
Agreeineni, Grantee will repair all conditions or damages to the streets and side�va]ks or other
rights-of-way �hat have resulted from Grantee's use or occupancy of the stt�ets and sidewaiks or
other rights-of-way, as determiued by the Direc�or of Transportatiou and Pubiic Works or his
designee. Grantee agrees to begi❑ such repairs within thirty (30) days of receipE of notice frocn
the Director of Transpo�-tation and Pub{ic Works or l�is desiguee. Atl repairs shall be performed
in an espediiious and �vorkmanlike manner and shalI comply with all applicable larvs, codes,
ordinances �€�� City specifications.
[n the event that Grantee fails to compl}� �ith the covenaufs herein contained with respect to
such rernoval ar restoratton, flie City shall have the r.igilt to remove ar ciispose of any barricades,
equipment, supplies, rtlaterials or other property and repair any conditions which in the opinion of I
t�e City are necessary to bring the public rights-of-�vay to the condition prescribed herein, and �
City shall not be responsib[e for trespass or any other damage or liability ir� connection wieh stiich ;
removal or restoration. Grantee shall reimburse City for the cost and expense of such removal
and/or repairs irnmediately following billing for sa�ne by City.
-__ --- _ _
� , � � ,' ��
��:T(�',i�.iL'1 ��;,
3 r� �/� � �' I
CONSENTAGREEIAENTtorTempararyvseafpublicpropestyi�doo � �� � �S �i!��'� � : i
- _, . . .; S �� .... .. . . . � .
� .,�5� '�.'i ; � �\ LI I, � .I+. , -
�.�1 J� . ��: ,� ;
�
Nothing herein shall be construed as a�vaiver by City to enforce penal sanctions prescribed
by t�ie Code oi the City oi Fort �jorth and the la�vs of the State of Texas for C�rantee's continued
encroachinent upon the pt�bIic rights-of-way folIowing terminatiom of this Consent Ab eement.
lfl.
It is fiu-ther undei-stood aild agreed between the parties hereto thai City holds �1ze cit}� streets,
alleys, sidewall:s and ot.her pubIic rights-of-way, including the portions af such streets used and
encroached upon as described herein,�as trustee for the public; that City e;cercises sucf� powers
over ��ie streets as have been delegated to it by the Constitution of the State of Texas or by the
Legislaiure; and tiie City cannot contract away its duty and its legislative power to cont�•ol the
streets for tlze use and benefit of the public, It is accordingly a�eed fIlat if the bovet�aing body of
City, to Evit, ifs City Council, shall at any time dui•ing ihe term hereof determine fn tts sole
discretion to tise or cause or permti to be used for any public purpose tize said efleroached portion
of the streets, then this agreement shall be automatica{ly cancelecl and terrttinated.
tiy
11.
Grantee agrees to co7nply fiil3y �vith aIl appiicable federal, state and local laws, statutes,
ordinances, codes or regttlations ii� connection with the consfrucfion, operation and maintenance
of said encroachments and uses.
12.
Grantee agrees to pay pramptly �vhen due all fees, taxes nr rentals p►-ovided for hy this
agreeinerrt oE� by �ny fecferal, staie or (ocal stai�ie, law or regaiation.
13.
Grat�tee covenants and ab ees that it shall exercise all rights and privileges b anted hareunder
as an i��dependent contractor, and not as an o�cer, agent, se�vant or employee of City; tfiat
Grantee shall have exc(usive control of and the exclusive right to control the cfetails of its
opera(:ions and activities on said described public pro�erty and all persons performing same, and
shall be solely responsible for the acts and omissions oi ifs ofFicers, agents, servants, e�ployees,
contractors, subcontractors, licei3sees and invitees; tbat the doctrine of respondeat snperior shall
nof apply as between City and Grantee, its o�cers, agents, servants, employees, contractors and
subcon�rac�ors, and nothing herein shall be construed as creating a partnership or joint enterprise
bettiveen Ci�y and Grantee.
4 CQNSENT AGREEb7ENTfcr Temporary usa of public prooertlt.doc
i
� ` , ., ,_ � G r ^:,
:����� 1�, �����,��:��;
�' � !
� (;� :,r �� i5s'',
; �., '� � 6 v S e t.,
i 5� ;r'Y i�j U; "f;
�.�.J �� ..;ri'1:Ldi'y j1._,
��.
�RANTEE COVENAR'TS AIi�D AGIZEES TO II�IDE[��1i �'Y, Ai1ID DOES HEI2EBY
�i �EN�'Y, HO�,D HARi�ESS Ai�ID DEFEND CITY, ITS {)F�'ICERS, AGEIVTS, �
SERVANTS IiNI3 E�'L�YE�S, FROIVI AND AGAL�TST ANY ril+£D ALL CLAIiY�S Ol� 1
�UITS FOR PROPERTY DAlY1AG� �R LOSS AND/OR P�RSflNAL IlVTURY,
CiVCLUDIl�IG I��ATH, TO ANI' AND ALL PERSON�, OF WHATSOEVER KIlYl� OR i
C�IARACT'�R, `VHETI�ER REAL OR ASSERT�D, AR�S�IG OUT OF OR IlY �
�ON�TECTION W�TH, DIItECTI.Y OR ]NDIRECTLY, THE NIAii�'IcEN�TCE, =
OCCUPANCY, U��, EYIST�NCjE OR LOCATTOlV OF SAID ENCROAC�NT AND (
USES GRANTEi) HEREUNDER, WHET�-IER OR NO'� CAU��, IN WHOI,E OR PAl2'I',
BY ALI,EGED NEGLIGEI�TCE OI' OFT'IC�RS, AG�NTS, S�RVANTS, EV�LOYEE9, ;
CONTRAC7'ORS, SUBCONTRACTORS, LIC�I�SEES OR PIVITEES OF CTTY; AND
GRA.NTE� H�R�BY ASS�T�Y�S ALL LIABiLITY AND It�SPONSIBILITY O�' CITY,
ITS OFFIG`ER5, AGEIVTS, SERVANTS AND EMPLOYEE�, I+OR SUCH CLAIlVIS OR
E
SUITS. GItA2VTEE SHAL�, LIKEWLSE ASSUME ALL LIABiL.�TY ANll
LZt;S�'VI`tS1li1L'1lY P.1'Vl� Jti?,LL 11V1JL1Y1I�11i{�Y LI1 Y FC3tC AiVY t�1V1� ALL LLVJUIIY GtC i
i
DAMAG� TO CITY PR�PERT`Y, ARISII�G OUT OI+ OR L�T C�NNECTTON WITH
AiVY A'�ID AI,U ACTS OR �NIISS30I+TS OF GRANT�E, IiS Or+'�'yC]CRS, AG�NTS,
S�RVANTS, E11�TPLf3YE�5, CONTRACTORS, SUBCONTRACTORS, LICESNEES,
;
INVITLES OR �'12�SPASSERS. !
f5.
Grantee agrees to furnisli Clty with a Certificzte of Insurance, naming City as certificate
holder, as proof t�at it has secured and paid for a policy �f public tiability ins�irance covering aIl
public risks related to ihe proposed use and occupancy oi pubtic properry as located and
described in Exhibit "B". The amounts of st�ch insurance sliall be not Iess that �he following:
Property damage, per occun-ence $1 QO,OOO.t�O
i
Bodity tnjury, per person $250,000_00 �
Boc�ily inj�try or death, per occurrence �500,000_00 .
W ith tfie understanding of and agreement by Grantee that such insurancc amounts shall be revised ;
up�vard at City's option and that Grantee sY�al1 so revise sttch amount immediately foIlowing
notice to Grantee of such requirement. Sucl� insurance policy sha1I provide tUat it cai�not be �
canceled �r amznded witflout at least thirty (30) days' prior writ-�en notice to t�e BuiIding Ofr�cial � '
� _� � r
; •�
5 ! J J"vl� ;'
i
CONSEi�'TAGREEFdENTforTempararyuseofpuhficpropert�l.dncE ��ti(',' c�,'
I I� �., � r'_, � r . .
-�:i2 i�f � I� :i
of tile Ciry oi Fort Worth. A copy of such Certificate of Insurance is attached as EYhibit "A".
Grantee a�-ees to submit a similar Certificate of Insurance ai�nualiy to City on the anniversary
date of t1Ze eYecution of this ab eement.
Grantee, agrees, binds and obligates itselr it successors and assigns, to maintain and keep in
foFce such public iiability insurance at all fimes during the term of this agreement and uiiti? the
reu�ovai of afI encioachments and the c3eaning and restoration af the city streets. AII insurance
coverage reqtiiired herein shal I inclutl.e coverage of all Grantee's contractors.
16.
Grantee covenants and agrees that it �vili not assign ail or any of its rights, privileges or duties
under this contract without prior written approval of City, and any attempted assignment without
such prior written approval shall be void. � �
17.
TIlis agreement sha(I be binding upon the parties hereto, their successors and assigns.
18.
Should 1ny action, whether real or asserted, at ]ativ or in ec�uiEy, arise out of the terms and
conditions of this agreement or out of the use a�td occupaucy of C[fy property as permitted
hereur�der, venue for said action shali be in Tarrant County, Texas.
19.
In any action brougl�t by City for t�ie enforcement of fhe obligations of Grantee, City shall be
entitled to recover interest dnd reasonable atfomeys' fees.
/� �1Dor1
EXECUTED this �. day of / 1� , 298�
GRANTOR_ GRANTEE: ( �
CITY OF FO�ZT �VORTH
-- � //cfis��' � � V�fi`rY.�Y
Bui lding Official � � �
!/• l•
Title
6
CONSENT AGREEMENTfor Temperary use o( public Oroper(ytdoc
A ROV�D TO FOR��`f�ND T.EGALTTY:
� � � ��'i��'�U���
Assistant Ci'ry Attorney
�� .
City Secretary
I�t� �t�c� �t�;(�I1Ikt�� i.e
� � �� .�
D ate
�� �
� �
Daie
€ __,. �I� ,— ,� -�, ..�� _�I
�� �
:�'r�� �v��.�� �?�'ul)�1'u��
(�„
N 1 iFi �,n5�� n.
CONSENTAGREEMEKTforTgrporaryuseo£G�bl�proq@�i'Y�.�'oc���lJ�41�/�II/tl�;`� �
IFi1:
� � �� °:�U n�
� °�?i:,,1 'I R
j �L� �'' �J�1• fC� Y�G o �
f
. . .�--_� ""'"--�e.r_ ,. : -. .
STATE OF TEXAS
CO UNTY OF TARRANT
BEFORE NIE, tlte ai�ic�erszg�ie�l aa�tfao�•ity, a Notary Public i�i �i�id
F/�r lie S,J�n e of Texas, o�i this day persorially appearetl
L�,�� ����v�J ,k�iowri to nie to be tlie perso�z tivhose
�1m�re is saibscribetl to tlte for�egoiizg i�zstruilie�zt, a�ad ack�lowledged to tne
tltcrt Ire/slze execirterl the sa�rte for ta pitrposes aizd co�zsideratio�i tltef�ei�z
eYpressed, as the �ct �cud deed of `_ ' �� '
�zn�l in tlze capacit�� therei�z stated.
GIVEN UNDER MYHAND AND SEAL OF OFFICE tlzis _�—`� ��Y
o� 20�'.
� ��
Affiartt
, , �%I (
� n �c�
Title
� � � ��
Nota�y Ptrblic i�i c�nd for �
Tlte State of Texas
8
�_�-�__�����-�_
,,,�„�,,,,
,olParrue��., t�. G. NAREZ
'�:' ": Notary Public, State of Texas
' � ' ° My Commission Er,pires
'''�i�F�F�E��```` September 10, 2009
/� Illll���`
, , ,
� J1 � i I�'., i�.�L��. ..�
�.+� �" ,i,!7+11'�� l��'�i"c�
ii I� i� .'�1�i � I!;._�, �al �i
Vi�� .�-- �
��� -�:����a�f�l �Ct\q` �
�i� �o ...����t•:G�ill� �IuG',1� }
.S'?��1T1�'' �.��' :r�.��i��f�f�``i
�t:�U�7'�G�Ii "1',9RIc'.�fIVT
13Ela�ifl'd'[l;�Is. iire u,�r.l.�fSlj��T/�lf fil�i�f���fzt�, c, �Intrr���j ��1/t'1IlC It! n141f
.�'O/° «lC' �i'�(�tf'. `)i �1G':CC1S� r7Fi! 1fi75' f�fLV j'7G'Y�`(lFlf�flj7 (L�1�7��(lY(.'.!� � '� �', . :
�T,_ � ---- s%i11e51i�l1 !O 3YfC� �fJ I1C l��lL? �:�L�F';�OPI -UIl.'73'C�
n�a�ne r,s' suli,scr�rCier! i�� t]'ae,�bt��n�ot.rt,; itzstratt'r�<�rit, tcr�rl rrc/tr��n�i�l�ri�e�l to rtze
:'fl (lt jlE'�SjLP F.'.t'C�Ci{IE:I �{tE! Sfiil-'.C�� (}Y i'fae ��r�,�vnst�s rcyirf cnn,sirte�•�tientc tlr.e����ifz
� .,
•�X�JYNSSL'[�, US �`.KI'tf :�Li�l (f�''i(f �fC('l� .��� . v �,��,;. �,ut::-:`,� —
—.zr
:ZiF.lI Kt7. f{L{i C(LliilC'I�Jl CIIE'YG'LP! ,1P!/.IC4j-
���1.r��i:�,�v:�t;r� n��v��Fin�►� f�rv��,s�:��: t�� f�t��t���rrh��� 1e,�'���«y
�? f _� ' � - 1(1.� . �
� � .____...._..._.._
!I%�tcsti . , ------
_�_�`� /' -
"1'ille
t
� `���nrruS� � DONNA fREEMAN ��
_ `' : Notary Public, State of Texas �
_ ,;,�� - My Commission Expires I
t;
����'�'� February Q6, 2010 �
� ,y_ . -�,
,\iofr���y �'r�i�lrc z�� rey►tl. fnr
7'�ie.�taie of 7'e;:ns
n
M
�
N
N
�
�I
o;
+' I
m
olJ
N
�
� n
vi I U
� w
O p
'S v
a I �
W
i � j
� � I_
i t
�
O N
� y�
CD
/�L � � J �
( �
rt �
rn �
O � �
u1 ln
N II � II
�n J
� tv II F-
�� X � �-
lf1 0 N
N ,�
N X
X �
� �n O
m
x N N
O �� �n
O � N
� � II
�� � �
� J �
Y
rn �
� 3 �
m
ci a in
N N
� �
-,::� j�j 1^��,��_
,f -���J�:.�IG�!!` 1is�r~�;/.�;�t
c% �
- i�:+'p'I'21� ;\;;��';�i���is1�I�U�
�;; Y I! \°�4��]SuL
� Jy��' ^ �•ii i` ���lUl II'I�^��
_ l.`,'1.��3 ��G�:� �
ACORDTM CERTIFICATE OF LIABILiTY INSURANCE page � of 3 12/19/2006
PRODUCER g77-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AINEND, EXTEND OR
willie r�orth z.merica, znc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
26 Century Blvd.
P. O. Box 305191 NAIC#
Nashville, TN 372305191 INSURERS AFFORDING COVERAGE
INSURED Linbeck Group, L. P.
P. 0. Box 22500
Houeton, TX 77227
INSURER B:
INSURER C:
INSURERD:
INSURER E:
Zurich American
16535-
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.
INSR DD' POLICYEPFECTIVE POLICYEXPIRATION LIMITS
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MMIDD/YY
A X GENERALLIABILITY GL0209090508 ZZ�ZO�iOO6 ZZ�ZO�200% �CHOCCURRENCE $ i OOO OOO
DAMAGE TO RENTED
j[ COMMERCIAL GENERP,L LIABILITY PREIdISES Ea occurenca 8 S O O O O O
CLAIMS MADE � OCCUR MED EXP (M one person) $ 1 O O O O
PERSONAL&ADVINJURY S 2 OOO OOO
GENER4L AGGREGATE S 4 O O O O O O
PRODUCTS • COMP/OP AGG 5 4 O O O O O O
GEN'L AGGREGATE �IMITAPPLIES PER:
POLICY X JECT LOC
A X AUTOMOBILELIABILITY BAP209090308 ZZ�ZO�ZOO6 ZZ�ZO�2OOi COMBINEDSINGLELIMIT $ ].�OOO�OOO
(Ea accident)
}{ ANYAUTO
ALLOWNEDAUTOS BODILYINJURY �
(Per person)
SCHEDULED AUTOS
HIREDAUTOS BODILYINJURY $
(Per accident)
NON-OWNED AUTOS
PROPERTYDAMAGE �
(Per accident)
AUTOONLY-EAACCIDENT S
GARAGE LIABILffY
ANYAUTO OTHERTHAN �+ACC $
AUTO ONLY: AGG 5
EACHOCCURRENCE S
EXCESS LIABILITY
OCCUR � CLAIMSMADE AGGREGATE �
$
$
DEDUCTIBLE
$
RETENTION $ WC STATU- OTH-
A WORKERSCOMPENSATIONAND �WC209090208 �.Z�iO�iOO6 Zi�2O�i00% X TORYLIMITS ER
EMPLOYERS' UABILITY E.L EACH ACCIDENT 5 1 O � O O O O
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE- EA EMPLOYEE S 1 O O O O O O
OFFICER/MEMBER EXCLUDED7 �
If yes, desaibe under E.L. DISEASE - POLICY LIMIT 5 1 0 0 0 0 0 0
SPECIAL PROVISIONS below
OTHER •
DESCRIPTION OFOPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED 8Y ENDORSEMENTISPECIALPROVISIONS
For all City of Fort �4orth Projects.
Workers Compensation Coverage:
THE PROPRIETOR/ PARTNERS/EXECUTIVE ARE: INCLUDED
n\Il�CI I ATI(ll.l .,_.___. • �..e fn. Nnn-Pavment ___
CERTIFICATE HOLDER
The City of Fort Worth
311 W. lOth Street
Fort Worth, TX 76102
ACORD 25 (20D1108)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
�ATE THEREOF, THE ISSUING INSURER WILI. ENDEAVOR TO MAIL 3� DAYS WRITTEN
NDTICE TO THE CERTIFIGATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
UT ORIZEDREP{�ESE A
! � � I"'� � �
Co11:1836919 Tp1:576334 Cert:8266613 OACORDCORPORATION1988
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED �3Y tNuuKstmtn iiar��iN�rrtvrw��+�.�
The City of Fort Worth, its Officers and Employees are Additional Insureds on the general
liability and automobile liability policies, but only to the extend of the indemnity of the
contract and further subject to the terms, exclusions and conditions of the policy.
Wavier of subrogation in favor of the certificate holder(s) on the general liability and
automobile liability policies, but only to the extent of the indemnity of the contract and further
subject to the terms, exclusions and conditions of the policy.
C011:1CSb7t7 1Yt:.�iv.�oz �=i�..,�........_..
Page 3 of 3
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 fieu 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.
ACORD25(2001/08) Co11:1836y1y '1'pt:�/e.s.ss �erL:aa000i�