Loading...
HomeMy WebLinkAbout(0148) HD Waste GOP Application and COI.pdf1. Briefly describe the nature and character of the service the applicant proposes to render. Roll Off Dumpster rental 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 2 operate under this Agreement. 3. Do each of the vehicles listed in question 2 above have a current City of Fort Worth Hauling Permit? NOI Applicant has attached Cercated of Liability Insurance as required in i, Circle One the Non -Exclusive Privilege Agreement, section 13. YES NO 5. Signature of pers authorizi&d by the Company to sign this Application Signature Title Date ------------- For City---------------------- Use Only Privilege Agreement Number: Date Approved: Period Covered: to Approved M&C Number: — T — — — — — — — — — — — — — — — — — Distribution: �ity Secretary, To 7id Waste Division, Applicant ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 2/21/2020 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 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 Omega Insurance Services 648 N Interurban St. Richardson TX 75081 NAME: ItZel Cordoba (Atc. No, Ext): 469-567-3001 NE (AAiq No): 214-919-4021 ADDREss: admin@omega tx.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Hallmark Specialty Insurance Company 26808 INSURED HD Waste & Recycling LLC 10631 CF Hawn Fwy Dallas TX 75217 INSURER B : Hallmark County Mutual Insurance Company 29408 INSURER C : Texas Mutual Insurance Company 22945 INSURER D ! Certain Underwriters @ Lloyds 085202 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. IN RI LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE N OCCUR G42415297-1 5/21/2019 5/21/2020 EACH OCCURRENCE $ 1,000,000 PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PRO JECT ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ Included $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS X WNED HIRED AUTOS X AUTOS A42501723-5 3/7/2019 3/7/2020 (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPEH FY DAMAGE-- (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 0002044551 2/22/2020 2/22/2021 X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 B Physical Damage A42501723-5 3/7/2019 3/7/2020 Deductibles - Comp: $1,000, Coll: $1,000 D Physical Damage - 2019 Mack #4614 WL300AP18022 3/7/2019 3/7/2020 Limit: $Deductibles: $2,500 comp/coll DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Vehicles: [See Attached]; Drivers: [See Attached]; CERTIFICATF HO(_DER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Proofof Insurance AUTHORIZED REPRESENTATIVE no 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: AC®R®® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED OMEGA INSURANCE AGENCY HD Waste & Recycling LLC 10631 CF Hawn Fwy POLICY NUMBER A42501723-5 Dallas, TX, 75217 CARRIER NAIC CODE EFFECTIVE DATE: 3/7/2019 Hallmark County Mutual Insurance Company 29408 ADDITInNAI REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Vehicles: -2016, MACK, GU, VIN: 1M2AV04C3GM013723, Coverage Limit: $150,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -2003, MACK, CX, VIN: 1 M1 AE02Y23W001189, Coverage Limit: $20,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -2019, RAM, 5500, VIN: 3C7WRMDLI KG717486, Coverage Limit: $86,500, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -2002, MACK, CX, VIN: 1 M1 AE07Y32W012273, Coverage Limit: $20,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -2016, MACK, GU, VIN: 1M2AX13C6GM033885, Coverage Limit: $130,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -2019, MACK, Granite, VIN: 1 M2GR2GCXKM004614, Coverage Limit: $208,000, Deductible (Collision): $2500, Deductible (Comprehensive): $2500 -1998, MACK, MR, VIN: 1 M2K195C6WM011224, Coverage Limit: $20,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -2008, MACK, GU, VIN: 1M2AX04C18M0o3316, Coverage Limit: $35,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -2017, MACK, GU, VIN: 1 M2AX13C4HM038116, Coverage Limit: $194,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -1994, Tube, FB Trailer, VIN: 1 G9PT3325RA116019 -2004, FORD, F-650, VIN: 3FRNF65K74V604243, Coverage Limit: $20,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -2018, MACK, GU, VIN: 1 M2AX13C11M040766, Coverage Limit: $166,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 -2016, MACK, GU, VIN: 1 M2AX13C3GM033553, Coverage Limit: $145,000, Deductible (Collision): $1000, Deductible (Comprehensive): $1000 Drivers: -Name: Ricardo Malagon -Name: Carlos E Acosta -Name: Rodolfo Martinez -Aguilar -Name: Nathaniel Atondo -Name: Marcos Ledezma -Name: Hugo Martinez -Name: Javier Puga -Name: Jacobo Campos -Name: Timothy Booher III -Name: Carlos Acosta -Name: Juan Mendoza -Rodriguez -Name: Miguel Martinez ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD