Loading...
HomeMy WebLinkAbout(0149) Bin There Dump That GOP Application & COI.pdfFORT WORT Ra APPLICATION FOR NON-EXCLUSIVE PRIVILEGE AGREEMENT (Collection and Transportation of Municipal Solid Waste) INSTRUCTIONS: Complete form and return to City of Fort Worth, Solid Waste Management Division 4100 Columbus Trail, Fort Worth, TX 76133 Trade Name of Applicant J%o-Tbv -C Physical Address 01 KwM Cirm, P-.d r Contact Name k uk_s ) C o �k alD Contact v,3 _. Ni Mailing Address un 1 (ACA V, e( JX 1VL TelephoneNu ber� t�3-"_ 0 tS Fax Number 1. Briefly describe the nature and character of the service the applicant proposes to render. 0k)MhC'wf hr1k)Ur U(J'U . ffiNew" .iFvr IOUrnPSret� 2. Estimated Number of Vehicles Operating Under this Agreement. A list of all vehicles must be attached to this application. The list shall include make, model, year and license plate number of all vehicles to operate under this Agreement. I3. Do each of the vehicles listed in question 2 above have a current City of Fort Worth Haulinq Permit? I� 4. Applicant has attached Certificated of Liability Insurance as required in Circle One the Non -Exclusive Privilege Agreement, section 13. YES NO R.f.7-N 1NCl 5. Signature of person authorized by the Company to sign this Application Signature � ,NCAIJQA CO' —e Title V w n e i Date — -------------------------------- For City Use Only Privilege Agreement Number: Date Approved: Period Covered: to Approved M&C Number: — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Distribution: City Secretary, Solid Waste Division, Applicant A`C"R" CERTIFICATE OF LIABILITY INSURANCE °ATg,2ai2o20YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. 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 endorselnent(s). CONTACT PRODUCER Quirk & Company NAME: _ _ P.O. Box 792030 aC°No xt : 210.342.9421 (AI , No); 210.340.4075 San Antonio, TX 78279 .Mal -- - ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # www.quirkco.com INSURER A: Nautilus Insurance Company 17370 INSURED INSURER B; DLC Solutions, LLC Bin There Dump That INsuRERc: P.O. Box 1299 INSURER D : Keller TX 76244 INSURERE: INSURER F : rnvconr_cc rC0TIGIrAT9= MIIMRFR• �7917On7 REVISION NIIMRFR• 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. INSR LTR TYPE OF INSURANCE DL SU POLICY NUMBER MWDDY/YYYY MM/DD� LIMITS _ A ✓ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE �✓ OCCUR NN1015545 7/24/2020 7/24/2021 EACH OCCURRENCE __ $1,000,000DAMAG $100 000 $ 5,000 TO RENTED PREMISE Ee occurrence MED EXP (Any one person) PERSONAL & ADV INJURY $1 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ✓ JPRO- POLICY PRO ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ Included $00 Deductible AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ $ $ $ BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTYDAMAGE IPLr accident UMBRELLA I" EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE $ $ l $ HOCCUR AGGREGATE DELI I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUINE ❑ OFFICER/MEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A I PER OTH- STATUTE I I ER $ $ _ $ E.LEACH ACCIDENT E.L. DISEASE- EA EMPLOYEE E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) UANUtLLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Luis A. Vazquez �Jf © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD