HomeMy WebLinkAboutContract 62863Tier II Easement Encroachment Agreement Page 1 of 13
Revised 12/2022
Date Received: ________________ Record Number: PN24-00194
Time Received: ________________ City Secretary No.: _____________
PUBLIC PROPERTY EASEMENT ENCROACHMENT LICENSE AGREEMENT
TIER II
THIS AGREEMENT is made and entered into by and between THE CITY OF
FORT WORTH, a home rule municipal corporation of Tarrant County, Texas ("City"),
acting by and through its duly authorized City Manager, Assistant City Manager, or
Director of the Development Services Department, and Retail Corners, LLC, a Texas
limited liability company ("Licensee”), acting by and through its duly authorized
representative.
RECITALS
WHEREAS, Licensee is the owner of the real property located at 8652 Bryson
Lane, Fort Worth, Texas 76179 (“Property”), being more particularly described as, Lot
2R1, 2R2, 2R3 and 2R4, Block 1, of Miller-Nixon Addition, an addition to the City of
Fort Worth, Tarrant County, Texas, as recorded in Deed Records, by Instrument Number
D219107242; and
WHEREAS, the City owns water and sewer easements (the “Public Property”)
adjacent to the Property, dedicated by plat, depicted on the final plat of the property (FS-
24-147), which plat is recorded in the plat records of Tarrant County as Instrument
D225018684; and
WHEREAS, Licensee desires to construct, place, and maintain certain
improvements which will encroach in, on, above, or below the Public Property; and
WHEREAS, to accommodate the needs of the Licensee, the City will allow the
encroachment under the terms and conditions as set forth in this Agreement.
NOW, THEREFORE, the City and Licensee agree as follows:
AGREEMENT
1.
The City, in consideration of the payment by Licensee of the fee set out below
and covenants and agreements hereinafter contained to be kept and performed by
Licensee, hereby grants permission to Licensee to encroach in, on, above, or below and
occupy a portion of the City’s Public Property as described in and at the location shown
on Exhibit “A,” but only to the extent shown thereon, for the purpose of constructing,
Tier II Easement Encroachment Agreement Page 2 of 13
Revised 12/2022
installing, and maintaining private storm lines (the “Encroachment”). Upon completion
of the Encroachment, Licensee agrees to be responsible for maintaining the
Encroachment within the Public Property. Licensee shall not expand or otherwise cause
the Encroachment to further infringe in or on the Public Property beyond what is
specifically described in Exhibit “A.”
2.
All construction, installation, maintenance, and operation of the Encroachment
and the use or occupancy of the Public Property shall comply with and be performed in
strict compliance with this Agreement and with the charter, ordinances, codes, and
policies of the City. Prior to the construction or installation of the Encroachment,
Licensee shall submit a copy of all plans and specifications to the Director of the
Development Services Department or duly authorized representative. Licensee shall not
commence construction or installation of the Encroachment nor make any use of the
Public Property until after the execution of this Agreement.
3.
Licensee, at no expense to the City, shall make proper provisions for the
relocation and installation of any existing or future utilities affected by such
Encroachment and the use and occupancy of the Public Property, including the securing
the approval and consent of the appropriate utility companies and agencies of the State of
Texas and its political subdivisions. In the event that any installation, reinstallation,
relocation, or repair of any existing or future utility or improvements owned by or
constructed by or on behalf of the public or at public expense is made more costly by
virtue of the construction, maintenance, or existence of the Encroachment and use of
Public Property, Licensee shall pay to City an additional amount equal to such additional
cost as determined by the Director of Transportation and Public Works, the Director of
the Water Department, the Director of the Development Services Department, or their
duly authorized representative.
4.
Licensee agrees that City may enter and utilize the Public Property at any time for
any public purpose, including installing, repairing, replacing, or maintaining
improvements to its public facilities or utilities necessary for the health, safety, and
welfare of the public. The City shall have no responsibility or liability for any damages
related to the Encroachment resulting from the City’s use of the Public Property;
however, the City shall make reasonable efforts to minimize such damage.
5.
Upon termination of this Agreement, Licensee shall, at the option of and at no
expense to the City, remove the Encroachment and restore the Public Property to a
condition reasonably acceptable to the Director of Transportation and Public Works, the
Tier II Easement Encroachment Agreement Page 3 of 13
Revised 12/2022
Director of the Water Department, the Director of the Development Services Department
or their duly authorized representative. Any such removal of the Encroachment shall be
in accordance with then-existing City regulations and policies. It is understood and
agreed to by Licensee that if this Agreement terminates and Licensee fails to remove the
Encroachment and restore the Public Property, Licensee hereby gives City permission to
remove the Encroachment and any supporting structures from the Public Property, to
restore the Public Property, and to assess a lien on the Property for the actual costs
expended by the City in taking such actions.
6.
In order to defray all costs of inspection and supervision which the City has
incurred or will incur as a result of the construction, maintenance, inspection or
management of the Encroachment and use of Public Property as provided for by this
Agreement, Licensee agrees to pay to City at the time this Agreement is requested an
application fee in the sum of One Thousand Twelve Dollars and Fifty Cents
($1012.50).
7.
The term of this Agreement shall be for thirty (30) years, commencing on the
date this Agreement is executed by City. However, the City may terminate this
Agreement upon Licensee’s noncompliance with any of the terms of this Agreement
following applicable notice and cure period. City shall notify Licensee in writing of any
such noncompliance and if Licensee does not cure the noncompliance within thirty (30)
days of notice from City, the City may terminate this Agreement. However, the City may,
at its sole option, allow the Agreement to remain in effect so long as Licensee has taken
reasonable measures to cure the noncompliance or is continuing to diligently attempt to
remedy the noncompliance.
8.
It is further understood and agreed between the parties hereto that the Public
Property to be used and encroached upon is held by City as trustee for the public; that
City exercises such powers over the Public Property as have been delegated to it by the
Constitution of the State of Texas or by the Texas Legislature; and that City cannot
contract away its duty and its legislative power to control the Public Property for the use
and benefit of the public. It is accordingly agreed that if the governing body of City may
at any time during the term hereof determine in its sole discretion to use or cause or
permit the Public Property to be used for any other public purpose, including but not
being limited to underground, surface, or overhead communication, drainage, sanitary
sewerage, transmission of natural gas or electricity, or any other public purpose, whether
presently contemplated or not, that the parties agree to negotiate in good faith in order to
accommodate both the Encroachment and the public purpose.
Tier II Easement Encroachment Agreement Page 4 of 13
Revised 12/2022
9.
LICENSEE COVENANTS AND AGREES TO INDEMNIFY, AND DOES
HEREBY INDEMNIFY, HOLD HARMLESS, AND DEFEND CITY, ITS
OFFICERS, AGENTS, SERVANTS, EMPLOYEES, AND ELECTED OFFICIALS
FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS FOR PROPERTY
DAMAGE OR LOSS AND/OR PERSONAL INJURY, INCLUDING DEATH, TO
ANY AND ALL PERSONS, OF WHATSOEVER KIND OR CHARACTER,
WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION
WITH, DIRECTLY OR INDIRECTLY, THE CONSTRUCTION,
MAINTENANCE, OCCUPANCY, USE, EXISTENCE, OR LOCATION OF THE
ENCROACHMENT AND USES GRANTED HEREUNDER, WHETHER OR NOT
CAUSED, IN WHOLE OR IN PART, BY THE ALLEGED NEGLIGENCE OF
OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS,
SUBCONTRACTORS, LICENSEES, ELECTED OFFICIALS, OR INVITEES OF
THE CITY; AND LICENSEE HEREBY ASSUMES ALL LIABILITY AND
RESPONSIBILITY FOR SUCH CLAIMS OR SUITS. LICENSEE SHALL
LIKEWISE ASSUME ALL LIABILITY AND RESPONSIBILITY AND SHALL
INDEMNIFY CITY FOR ANY AND ALL INJURY OR DAMAGE TO CITY
PROPERTY ARISING OUT OF OR IN CONNECTION WITH THE
ENCROACHMENTS AND ANY AND ALL ACTS OR OMISSIONS OF
LICENSEE, ITS OFFICERS, AGENTS, SERVANTS, EMPLOYEES,
CONTRACTORS, SUBCONTRACTORS, LICENSEES, OR INVITEES.
10.
While this Agreement is in effect, Licensee agrees to furnish City with a
Certificate of Insurance naming City as certificate holder as proof that is has secured and
paid for a policy of public liability insurance covering all public risks related to the
proposed use and occupancy of public property as located and described in Exhibit “A.”
The amounts of such insurance shall be not less than
$1,000,000
with the understanding and agreement by Licensee that such insurance amounts may be
revised upward at City’s option and that Licensee shall so revise such amounts
immediately following notice to Licensee of such requirement. Such insurance policy
shall not be canceled or amended without at least thirty (30) days prior written notice to
the Building Official of the City. A copy of such Certificate of Insurance is attached as
Exhibit “B” and incorporated herein for all purposes. Licensee agrees, binds, and
obligates itself and its successors and assigns to maintain and keep in force such public
liability insurance at all times during the term of this Agreement and until the removal of
the Encroachment and restoration of the Public Property. All insurance coverage
required herein shall include coverage of all Licensee’s contractors and subcontractors.
Tier II Easement Encroachment Agreement Page 5 of 13
Revised 12/2022
11.
Licensee agrees to deposit with the City when this Agreement is executed a
sufficient sum of money to be used to pay necessary fees to record this Agreement in the
real property records of the county in which the Encroachment is located. After being
recorded, the original shall be returned to the City Secretary of the City of Fort Worth.
12.
Licensee agrees to comply fully with all applicable federal, state, and local laws,
statutes, ordinances, codes, and regulations in connection with the construction,
operation, and maintenance of the Encroachment and use of the Public Property.
13.
Licensee agrees to pay promptly when due all fees, taxes, or rentals provided for
by this Agreement or by any federal, state, or local statute, law, or regulation.
14.
Licensee covenants and agrees that it shall operate hereunder as an independent
contractor as to all rights and privileges granted hereunder and not as an officer, agent,
servant, or employee of City, and Licensee shall have exclusive control of and the
exclusive right to control the details of its operations, and all persons performing same,
and shall be solely responsible for the acts and omissions of its officers, agents, servants,
employees, contractors, subcontractors, licensees, and invitees. The doctrine of
respondeat superior shall not apply as between City and Licensee, its officers, agents,
servants, employees, contractors, and subcontractors, and nothing herein shall be
construed as creating a partnership or joint enterprise between City and Licensee.
15.
Licensee agrees and acknowledges that this Agreement is solely for the purpose
of permitting Licensee to construct, maintain, and locate the Encroachment over or within
the Public Property and is not a conveyance of any right, title, or interest in or to the
Public Property, nor is it meant to convey any right to use or occupy property in which a
third-party may have an interest. Licensee agrees that it will obtain all necessary
permissions before occupying such property.
16.
In any action brought by the City for the enforcement of the obligations of the
Licensee, City shall be entitled to recover interest and reasonable attorneys’ fees.
Tier II Easement Encroachment Agreement Page 6 of 13
Revised 12/2022
17.
The parties agree that the duties and obligations contained in Section 5 shall
survive the termination of this Agreement.
18.
Licensee covenants and agrees that it will not assign all or any of its rights,
privileges, or duties under this Agreement without the written approval of the City, and
any attempted assignment without such written approval shall be void. Notwithstanding
the foregoing, in the event Licensee conveys the Property, Licensee may assign all of its
rights and obligations under this Agreement to the new owner of the Property, and
Licensee shall be deemed released from its duties and obligations hereunder upon City’s
approval in writing of such assignment, which approval shall not be unreasonably
conditioned or withheld. Foreclosure by a secured lender of Licensee or assignment to a
secured lender by Licensee in the event of default or otherwise shall not require City
approval provided that said lender notifies City in writing within sixty (60) days of such
foreclosure or assignment and assumes all of Licensee’s rights and obligations hereunder.
However, no change of ownership due to foreclosure or assignment to any secured lender
of Licensee shall be effective as to City unless and until written notice of such
foreclosure or assignment is provided to City.
19.
Prior to the end of the term of this Agreement, Licensee may submit a new
encroachment application to the City. The City will not unreasonably withhold or delay
approval of such application provided that the Encroachment follows the then current
City codes and compliance.
20.
Any cause of action for breach of this Agreement shall be brought in Tarrant
County, Texas. This Agreement shall be governed by the laws of the State of Texas.
21.
This Agreement shall be binding upon the parties hereto and their successors and
assigns.
22.
Tier II Easement Encroachment Agreement Page 7 of 13
Revised 12/2022
This Agreement may be executed in multiple counterparts, each of which shall be
considered an original, but all of which shall constitute one instrument.
[SIGNATURES APPEAR ON FOLLOWING PAGE]
Tier II Easement Encroachment Agreement Page 8 of 13
Revised 12/2022
EXECUTED to be effective on the date signed by the City’s Director of
Development Services Department
City:
CITY OF FORT WORTH
By: ___________________________
D. J. Harrell
Director, Development Services Department
Date: ___________________________
ATTEST:Approved as To Form and Legality
______________________ _______________________________
Jannette Goodall, Hye Won Kim
City Secretary Assistant City Attorney
Contract Compliance Manager:
By signing I acknowledge that I am the person
responsible for the monitoring and administration
of this contract, including ensuring all performance
and reporting requirements.
__________________________________________
Rebecca Owen
Development Services Manager
Licensee:
Retail Corners, LLC
a Texas limited liabiiity company
B.
Name: David Hardesty
Title: Managir�g Member
Date: 5
STATE OF -��x a s
COUNTY OF D a� �� s
ra
ni
�
BEFORE ME, the undersigned authority, a Notary Public in and for the State of
TP,X q S , on this day persanally appeared David Hardesty, Managing Member,
kno�vn to me #o be ihe person whose name is subscribed to the faregoing instrument, and
acknowledged to me that he or she executed the same for the purposes and consideration
therein expressed, as the act and deed of Retail Corners, LLC, a Texas lirriited liability
company,and in the capacity therein stated.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this �� day oi
��. 2��5
Notary Pu ic a for the
State of S
�'ier II Easement Encroachment Agreeinent
,.��SP''�.,� AVERY OGNJAhRC
_�:�� c Noiary Public, Steta of Taxaa
%;�•.. ��: Comm. F.�Ires 0�1 �20Z6
''��n°�Fi�����` NOtery ID 1338$7B2-5
Page 9 of 13
Revised 12/2022
Licensee:
David Hardesty
c
Name: David Hardesty
Date: ��e �,a.,�v � . 2n,z�
STATE OF ��xaS _ §
COITN'TY OF � �, l, G�� _ §
BEFORE ME, the undersigned authority, a Notary Public in and for the State of
1�.Xa� , on this day personally appeared David Hardesty, known ia me ta be the
person whose nazx�e is su.bscribed #o the foregoing instrument, and acicr�owledged to me
that he or she executed the same for the purposes and considera�ion therein expressed, as
the act and deed of, and in the capacity therein stated.
GIVEN UNDER MY HAND AND SEAL OP �FFICE this �� day of
, �8�4. 2D Z �
Notary Public in and for the
State of TLKGI S
.....�.�
�,���"�, AVFRY �GNJAMAC
��� Yp �/i
� �,...,c� �+
: r°• X_ Notary Rublic. State of Texas
�� .�.' - Comm. F.�cpirea 08-16-2026
'�`,�,°f„�` Notery #D 13398782-6
Tier li Easement Encroachmenk Agreement
Page 10 of 13
Revised 12/2022
Tier II Easement Encroachment Agreement Page 11 of 13
Revised 12/2022
***THIS PAGE FOR CITY OF FORT WORTH OFFICE USE ONLY***
STATE OF TEXAS §
COUNTY OF TARRANT §
BEFORE ME, the undersigned authority, a Notary Public in and for the State of
Texas, on this day personally appeared D. J. Harrell, known to me to be the person
whose name is subscribed to the foregoing instrument, and acknowledged to me that he
executed the same for the purposes and consideration therein expressed, as the act and
deed of the City of Fort Worth, and in the capacity therein stated.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this_____day of
_____________, 202 .
__________________________________
Notary Public in and for the State of Texas
Tier II Easement Encroachment Agreement Page 12 of 13
Revised 12/2022
EXHIBIT A
Depiction and description of the Encroachment
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G:\2024\EASEMENTS\Miller-Nixon, Lot 2, Blk 1 - Encroachment Area - 0.009 Acre.doc
EXHIBIT “A”
LEGAL DESCRIPTION
ENCROACHMENT AREA
BEING 0.009 acre of land situated in the I. & G. N. R.R. CO. SURVEY, Abstract No. 834, Fort
Worth, Tarrant County, Texas, and being a portion of Lot 2, Block 1, Miller-Nixon Addition, to the
City of Fort Worth, Tarrant County, Texas according to the plat recorded in County Clerk’s File
No. D199258021, of the Official Public Records of Tarrant County, Texas, and also being a
portion of the tract of land conveyed to Retail Corners LLC and Equity Trust Company, by the
deed recorded in County Clerk’s File No. D219255125, of the Official Public Records of Tarrant
County, Texas. Said 0.009 acre of land being more particularly described by metes and bounds
as follows:
COMMENCING at a point lying in the South boundary line of said Retail Corners LLC and
Equity Trust Company Tract, and said point lying in the North right-of-way line of Bryson Lane (a
60 foot wide public right-of-way) and said POINT OF COMMENCING being the Southwest
corner of Proposed Lot 2R4, Block 1, Miller-Nixon Addition and the Southeast corner of
Proposed Lot 2R2, Block 1, Miller-Nixon Addition;
THENCE N 00° 48’ 27” W 18.78 feet, to a point;
THENCE S 89° 11’ 33” W 12.50 feet, to the POINT OF BEGINNING;
THENCE severing said Lot 2, Block 1, Miller-Nixon Addition and said Retail Corners LLC
and Equity Trust Company Tract, as follows:
1. N 00° 48’ 27” W 15.00 feet, to a point;
2. N 89° 11’ 33” E 25.00 feet, to a point;
3. S 00° 48’ 27” E 15.00 feet, to a point;
4. S 89° 11’ 33” W 25.00 feet, along to the POINT OF BEGINNING containing 0.009
acre (375 square feet) of land.
D225018684O.P.R.T.C.T.
G:\2024\EASEMENTS\Miller-Nixon, Lot 2, Blk 1 - Encroachment Area - 0.010 Acre.doc
EXHIBIT “A”
LEGAL DESCRIPTION
ENCROACHMENT AREA
BEING 0.010 acre of land situated in the I. & G. N. R.R. CO. SURVEY, Abstract No. 834, Fort
Worth, Tarrant County, Texas, and being a portion of Lot 2, Block 1, Miller-Nixon Addition, to the
City of Fort Worth, Tarrant County, Texas according to the plat recorded in County Clerk’s File
No. D199258021, of the Official Public Records of Tarrant County, Texas. Said 0.010 acre of
land being more particularly described by metes and bounds as follows:
BEGINNING at a point lying S 43° 11’ 23” W 255.12 feet, from a 5/8” iron rod marked
“GORRONDONA” found at the Northeast corner of Lot 2, Block 1, Miller-Nixon Addition, and
said point lying in the South boundary line of Lot 5, Block 1, Retail Corners Addition, to the City
of Fort Worth, Tarrant County, Texas according to the plat recorded in County Clerk’s File No.
D219080784, of the Official Public Records of Tarrant County, Texas;
THENCE severing said Lot 2, Block 1, Miller-Nixon Addition, as follows:
1. S 44° 11’ 33” W 15.91 feet, to a point;
2. S 00° 48’ 27” E 3.75 feet, to a point;
3. S 89° 11’ 33” W 25.00 feet, to a point;
4. N 00° 48’ 27” W 15.00 feet, to a point;
5. N 89° 11’ 33” E 36.25 feet, to the POINT OF BEGINNING containing 0.010 acre
(438 square feet) of land.
D225018684
O.P.R.T.C.T
.
D225018684
D225018684
O.P.R.T.C.T.
O.P.R.T.C.T.
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Tier II Easement Encroachment Agreement Page 13 of 13
Revised 12/2022
EXHIBIT B
Certificate of Insurance
DATE (MM/DDIYYYY)
A�� �� CERTIFICATE OF LIABILITY INSURANCE 1/27/2025
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
Nanne: service@dextercompany.com
Dexter & Company PHONE Fax
3601 Cedar Springs Rd. aic No exc : 214-526-5646 aic No : 214-526-6926
Dallas TX 75219 aooR�ess: service@dextercompany.com
INSURED
Retail Corners LLC
14228 Midway Rd Suite 204
Dallas TX 75244
COVERAGES
INSURER(S) AFFORDING COVERAGE
a: Mount Vernon Specialtv Insurance C
RETACOR-01 INSURER B :
INSURER C :
INSURER D :
INSURER E :
CERTIFICATE NUMBER:945495873
REVISION NUMBER:
NAIC #
14420
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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR IN POLICY NUMBER MM/DDMlYY MM/DDMlYY
A X COMMERCIAL GENERAL LIABILITY GL 2005681 D 7/29/2024 7/29/2025 EACH OCCURRENCE $ 1,OOQ000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ 100,000
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $2,000,000
X POLICY � PR� � LOC PRODUCTS - COMP/OP AGG $
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTYDAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$
UMBRELLALIAB OCCUR EACHOCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS' LIABILITY Y� N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBEREXCLUDED? � N�A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
REF# PN24-00194
CERTIFICATE HOLDER
City of Fort Worth
100 Fort Worth Trail
Fort Worth TX 76102
ACORD 25 (2016/03)
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.
AUTHORIZED REPRESENTATIVE
�" ��---�
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