Loading...
HomeMy WebLinkAbout(0144) Bubba Tugs GOP Application, COI, Vehicle List 11-17-2020_0.pdfFoRTWORTH. 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 Bubba Tugs Corporation Physical Address 4340 N Central Expy, Ste 100, Dallas, TX 75206 Contact Name David Cathcart Contact 214-935-8860 Mailing Address 4340 N Central Expy, Ste 100, Dallas, TX 75206 Telephone Number 214-935-8860 Fax Number 469-930-9677 1. Briefly describe the nature and character of the service the applicant proposes to render. ilection for d le m 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 7 operate under this Agreement. 3. Do each of the vehicles listed in question 2 above have a current City of Fort Worth HaulingPermit? NO 4. Applicant has attached Certificated of Liability Insurance as required in Circle One the Non -Exclusive Privilege Agreement, section 13. ES NO Signature of pers orized b the Company to sign this Application Signature Title CFO Date 11/17/2020 ---------------- For City Use Only Privilege Agreement Number: Date Approved: Period Covered: to Approved M&C Number: ©istribut W City Secretary, Solid Waste Division, Applicant F - - - - - - - - - - - - - AC40 " CERTIFICATE OF LIABILITY INSURANCE DArE(MMIDDlYYYY) �..� .� 11117/2020 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 endorsement(s). PRODUCER CONTACT David Jensen NAME: Higginbotham Insurance Agency, Inc. PHONE FAX VC No): 817-347-6981 • 817-349-2417 'VC, 500 W. 13TH ADDRESS: djensen@higginbotham.net Fort Worth TX 76102 INSURERIS) AFFORDING COVERAGE NAIC # INSURERA: James River Insurance Company_ 12203 _ INSURED 8UBaA3 INSURERS: Commerce and Industry Insurance Company 19410 Bubba Tugs Corp. 4340 N. Central Expressway INsuRERc:Texas Mutual Insurance Company....­_22945 INSURERD: Hallmark Insurance Company 34037 Dallas TX 75206 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:480320015 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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. 1NSR LTR TYPE OF INSURANCE ADDL INSD SUBR POLICY NUMBER POLICY EFF MM1DDIYY POLICY EXP MMIDDNYYY LIMITS A X I COMMERCIAL GENERAL_ LIASILrrY 000789202 8/23/2020 8/2312021 EACH OCCURRENCE $1,000,000 CLAIMS -MADE 1�1 OCCUR IIAMAOE TO RENTED PREMISES (Ea omurrrence) $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $1,000.000 LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $2,000,000 PRODUCTS- COMPIOP AGG_$2,000,000 � �^ IOTHER: POLICY E° LOC $ D AUTOMOBILE LIABILITY BU6142 $I2312020 13123/2021 COMBINED SINGLE LIMIT Ea accident $1 000 000 BODILY INJURY (Per person) $ ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) S PROPERTY DAMAGE Par acc€dent $ B UMBRELLALIAB 11 X OCCUR BE034236666 W23/2020 8i2312021 EACH OCCURRENCE $$1,000,000 X AGGREGATE $ $1,000,000 EXCESS LIAR CLAIMS -MADE DED I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERIEXEGEITIVE Y� 0001264403 2/5/2020 2!5/2021 X 15 TH STERATUTE ER E.L. EACH ACCIDENT $ 1,000,000 OFFICERlMEMBEREXCLUDED? (Mandatory in NH) NIA E.L. DISEASE- EA EMPLOYEE $ 1,000.000 E.L. DISEASE- POLICY LIMIT $1,000,000 ]f 7r�s, describe undar DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The General Liability (Includes Completed Ops) and Automobile Liability policies includes a blanket automatic additional insured endorsement that provides additional insured status and a blanket waiver of subrogation endorsement to the certificate holder only when there is a written contract between the named insured and the Certificate holder that requires such status. The General Liability policy has a blanket Primary & Non Contributory endorsement that affords that coverage to certificate holders only where there is a written contract between the Named Insured and the certificate holder that requires such status. The Automobile Liability policy includes a blanket notice of cancellation to certificate holders endorsement, providing for 30 days' advance notice if the policy is See Attached... City of Fort Worth Solid Waste Management Division 4100 Columbus Trail Fort Worth TX 76133 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AesENCY CUSTOMER ID: BUBBA3 LOG #: AC EP ADDITIONAL REMARKS SCHEDULE Page j of i L f- - AGENCY Higginbotham Insurance Agency, Inc. NAMED INSURED Bubba Tugs Corp. 4340 N. Central Expressway Dallas TX 75206 POI.JCY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ACORD 101 (2008/01) W LUU5 Al-UMI3 C VRrUMA IRVIN. /All FlUU , FC5UIVau. The ACORD name and logo are registered marks of ACORD Company Name:. BUBBA TUGS CORPORATION NO YEAR MAKE MODEL TYPE VEHICLE [D# (VIN) LICENSE PLATE# 1 2007 MACK 700 1 M2AG11C27M047236 KRM5411 2 2007 MACK TR 1 WAG11C27M056955 NFL6915 3 2005 MACK 700 1WAG11C05M030111 LSK3857 4 2D07 MACK CT7 1 M2AL02C37M007512 MYV6955 5 2006 MACK DM600 1 M2B209C66M030813 BY53923 6 2004 KW TSO 1 NKDLB9X34J059028 MYV7605 7 1998 MACK DM600 1 M2B209CXWM023069 FXS6181 Bubba Tugs Corporation 4340 N Central Expy # 100 Dallas, TX 75206 PAY HE of 11800 2 29 I'll 1: 1110006 L4i: Chase Bank Dallas, TX 75201 2291 www.chase.com DATE Ll 7— 32-61/1110 $ X/Cl I DOLLARS a. I 56 S 26 2800 -4�