HomeMy WebLinkAbout065454 - General - Contract - Columbia Plaza Medical Center of Fort Worth Subsidiary, L.P.Date Received: 6/29/2026
Time Received: 10 : 4 7 a.m.
Record Number: PN25-00217
City Secretary No.: 65454
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 COLUMBIA PLAZA
MEDICAL CENTER OF FORT WORTH SUBSIDIARY, L.P., a Texas limited
partnership ("Licensee"), acting by and through its duly authorized representative.
RECITALS
WHEREAS, Licensee is the owner of the real property located at 1901
Pennsylvania Ave, Fort Worth, Texas 76104 and 1725 Pruitt Street, Fort Worth, Texas
76104 (individually and together, the "Property") all situated in the George Shields
Survey Abstract No. 1402, Tarrant County, Texas; and
WHEREAS, the Property located at 1901 Pennsylvania Ave, Fort Worth, Texas
76104 is particularly described as, being a portion of Lot 2-A-R, Block 2, Medical Centre
Addition, an addition to the City of Fort Worth, Tarrant County, Texas, as recorded in
Tarrant County Deed Records, by Instrument Number D 195018237 and depicted on the
final plat of the Property (FP-14-032), which plat is recorded in plat records of Tarrant
County as Instrument Number D214159808; and
WHEREAS, the Property located at 1725 Pruitt Street, Fort Worth, Texas 76104
is particularly described as being a tract of land being a portion of Lot 3R, Block 7,
Edwards Heirs Addition, an addition to the City of Fort Worth, according to the plat
recorded in Cabinet A, Slide 2090, plat records, Tarrant County, Texas; and
WHEREAS, the City owns a water line easement and a sanitary sewer easement
(the "Public Property") within the Property, dedicated to the City in an easement filed
in the Tarrant County Deed Records as Instrument Numbers D213301040 and Cabinet A
Slide 2090, as depicted on the final plat of the Property (FP-14-032), which plat is
recorded in the plat records of Tarrant County as Instrument Number D214159808;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.
OFFICIAL RECORD
Tier 11 Easement Encroachment Agreement CITY SECRETARY Page 1 of 12
Revised 12/2022
FT. WORTH, TX
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,
installing, and maintaining a retaining wall and fence (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 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.
0
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.
Tier II Easement Encroachment Agreement Page 2 of 12
Revised 12/2022
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 acceptable to 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. 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 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.
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
Tier 11 Easement Encroachment Agreement Page 3 of 12
Revised 12/2022
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.
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
Tier II Easement Encroachment Agreement Page 4 of 12
Revised 12/2022
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.
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
Tier II Easement Encroachment Agreement Page 5 of 12
Revised 12/2022
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.
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. 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.
Tier II Easement Encroachment Agreement Page 6 of 12
Revised 12/2022
22.
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 11 Easement Encroachment Agreement Page 7 of 12
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: Dalton Harrell (Jun 29, 2026 08:53:11 CDT)
D. J. Harrell
Director. Development Services Department
Date: 06/29/2026
Qooavan
ATTEST:=s o=d ; Approved As To Form and Legality
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Jannette Goodall, Tayler Canton
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.
Kandice Merrick
Contract Compliance Manager
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Tier II Easement Encroachment Agreement Page 8 of 12
Revised 12/2022
Licensee:
COLUMBIA PLAZA MEDICAL CENTER OF FORT WORTH
SUBSIDIARY, L.P., a Texas limited partnership
By: COLUMBIA NORTH TEXAS SUBSIDIARY GP, LLC
a Texas limited liability company, its general partner
`2 ,
By:
Todd Maxwelf, Vice President
Date: June ZS , 2026
STATE OF TENNESSEE §
COUNTY OF DAVIDSON §
BEFORE ME, the undersigned authority, a Notary Public in and for the State of
Tennessee, on this day personally appeared Todd Maxwell, as Vice President,
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 Columbia North Texas Subsidiary
GP, LLC, a Texas limited liability company, the general partner of Columbia Plaza
Medical Center of Fort Worth Subsidiary, L.P., a Texas limited partnership, and in
the capacity therein stated.
GIVEN UNDER MY HAND AND SEAL OF OFFICE this q2�d'ay of
June, 2026.
EN Vv S^
OF
tary Public in and for the �: TENNE m
NOT SSFE : X
UBAR
State of Tennessee LI
'SC
s/OBE P IRES
Tier 11 Easement Encroachment Agreement Page 9 of 12
Revised 12/2022
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 29th day of
June 2026.
Notary Public in and for the State of Texas
Tier 11 Easement Encroachment Agreement
Au4ray Lae Wallac6
My Commisolon Expirem
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911012028
Notary kD135082586
Page 10 of 12
Revised 12/2022
EXHIBIT A
Depiction and description of the Encroachment
Tier II Easement Encroachment Agreement Page 11 of 12
Revised 12/2022
LEGAL DESCRIPTION
EASEMENT ENCROACHMENTS
BEING a 116 linear foot tract (Tract 1), being part of Lot 2-A-R, Block 2, Medical Centre, an addition to the City of Fort
Worth according to the plat recorded in Instrument No. D214159808, Official Public Records, Tarrant County, Texas,
and an 8 linear foot tract (Tract 2), a 15 linear foot tract (Tract 3) and a 15 linear foot tract (Tract 4), being part of Lot
3-R, Block 7, Edwards Heirs Addition, an addition to the City of Fort Worth according to the plat recorded in Cabinet
A, Slide 2090, Plat Records, Tarrant County, Texas. all situated in the George Shields Survey, Abstract No 1402,
City of Fort Worth, Tarrant County, Texas, and being more particularly described as follows:
TRACT 1
COMMENCING at a 1/2-inch iron rod with cap stamped "WIER & ASSOC." found at the southwest corner of said Lot 3-R, and
being in the north right-of-way line of Cooper Street, a variable width right-of-way;
THENCE North 00°10'02" East, along the west line of said Lot 3-R. a distance of 271.91 feet to a 5/8-inch iron rod found at the
beginning of a tangent curve to the right with a radius of 1477.25 feet, a central angle of 2'47'18", and a chord bearing and
distance of North 01 °33'41" East, 71.89 feet,
THENCE in a northerly direction, continuing along the said west line, with said tangent curve to the right, an arc distance of
71.89 feet to the POINT OF BEGINNING,
THENCE South 89'35'15" West, departing the said west line, a distance of 6 19 feet to a point for corner,
THENCE North 0°24'45" West, a distance of 74.76 feet to a point for corner,
THENCE North 11'56'17" East. a distance of 24.81 feet to a point for corner.
THENCE North 89'34'36" East, at a distance of 10.06 feet to the POINT OF TERMINATION. being at the northwest corner of
said Lot 3-R.
Ili:111101 a
COMMENCING at a 1/2-inch iron rod with cap stamped "WIER & ASSOC." found at the southwest corner of said Lot
3-R, and being in the north right-of-way line of Cooper Street. a variable width right-of-way,
THENCE North 00°10'02" East, along the west line of said Lot 3-R, a distance of 271.91 feet to a 5/8-inch iron rod
found,
THENCE North 66°41'43" East, departing the said west line, a distance of 89.57 feet to the POINT OF BEGINNING,
being on the west line of a 15-foot sanitary sewer easement shown on the plat of said Lot 3-R, Block 7,
THENCE North 89'35'15" East, a distance of 8.27 feet to the POINT OF TERMINATION.
EASEMENT ENCROACHMENTS
GEORGE SHIELDS SURVEY,
ABSTRACT No. 1402
CITY OF FORT WORTH
TARRANT COUNTY, TEXAS
LEGAL DESCRIPTION
EASEMENT ENCROACHMENTS
TRACT 3
COMMENCING at the west end of Tract 2,
THENCE North 01 °20'53" East, along the west line of the said 15-foot sanitary sewer easement, a distance of
37.02 to the POINT OF BEGINNING:
THENCE North 89'35'15" East, a distance of 15.01 feet to the POINT OF TERMINATION being in the east line
of the said 15-foot sanitary sewer easement.
TRACT 4
COMMENCING at the west end of Tract 3,
THENCE North 01 '20'53" East. along the west line of the said 15-foot sanitary sewer easement, a distance of
99 01 to the POINT OF BEGINNING.
THENCE North 89'35'15" East, a distance of 15.01 feet to the POINT OF TERMINATION being in the east line
of the said 15-foot sanitary sewer easement.
NOTES
Bearing system based on the Texas Coordinate System of 1983 (2011 adjustment), North Central Zone (4202)
A survey plat of even survey date herewith accompanies this metes and bounds description.
The undersigned, Registered Professional Land Surveyor, hereby certifies that the foregoing description accurately
sets out the metes and bounds of the encroachment tracts.
Az 0. 4 c --
JOSHUA D. WARGO
REGISTERED PROFESSIONAL
LAND SURVEYOR NO. 6391
801 CHERRY STREET,
UNIT 11 SUITE 1300
FORT WORTH, TEXAS 76102
PH. 817-335-6511
josh.wargo@kimley-horn.com
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JOSHUA D. WARGO
..................................
6391
C••'.0 OC'PO
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EASEMENTENCROACHMENTS
GEORGE SHIELDS SURVEY,
ABSTRACT No. 1402
CITY OF FORT WORTH
TARRANT COUNTY, TEXAS
I P.O.T. P 0 B. PRUITT STREET
I TRACT, (A VARIABLE WIDTH RIGHT -OF WAY)
I L4 � L5 NORTH
I _ ` _
T 0 30 60
I '' TRACT 4 I P.O.T.
TRACT 1 I I 15' SANITARY SEWER
I I EASEMENT GRAPHIC. SCALE ;, .EFT
CAB. A. SL. 2090
LOT 2 A R. BLOCK 2 1 I P.O.B. I I LOT 3-R, BLOCK 7
MEDICAL CENTRE I JRACT] NI ( EDWARDS HEIRS ADDITION
INST NO. D214159808 I P.O.. ZI I CAB. A, SL. 2090 I
TRACT, L6I� P.O.T. LEGEND
P.O.B. TRACT 3
CITY OF FORT WORTH I TPA.,T ,
L1 � P O C = POINT OF COMMENCING
WATER LINE EASEMENT I I P O B =POINT OF BEGINNING
INST. NO. D213301040 `I —�I P.O.C. I TRACT 2 TRACT ] P O T = POINT OF TERMINATION
gyX P.O.T. IRFC = IRON ROD W/CAP FOUND
R=1477 25' N66 j 4 a� I L$ IRF =IRON ROD FOUND
L=71 89' I I P.O. B.
CB=N1'33'41"E
C=71189' 518IRP
I
I
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I o I I
0
Z
P.O.C. ��\\
TRACT i S 2 \ 1/[ IRFC
T NFR s ASSOC
0'RF1 COOPER STREET
(A VARIABLE WIDTH RIGHT-OF-WAY)
NOTES
LINE TABLE
NO
BEARING
LENGTH
L1
S89'35'15W
619'
L2
N00 24'45"W
74 76'
L3
N11'56'17"E
24 81'
L4
N89134'36"E
10.06'
L5
N89'35'15"E
15.01'
L6
N89'35' 15"E
15.0 F
L7
LL8
N01'20'53"E
37 02'
N89'35'15"E
8 27'
Bearing system based on the Texas Coordinate System of 1983 (2011 adjustment), North Central Zone (4202)
A metes and bounds description of even survey date herewith accompanies this survey plat.
The undersigned, Registered Professional Land Surveyor, hereby certifies that this survey plat accurately sets out
the metes and bounds of the encroachment tracts.
/J/-,z `'. V-,/ -
JOSHUA D. WARGO
REGISTERED PROFESSIONAL
LAND SURVEYOR NO 6391
801 CHERRY STREET,
UNIT 11 SUITE 1300
FORT WORTH, TEXAS 76102
PH. 817-335-6511
josh.wargo@kimley-horn com
1 AM
ST fR.cF
JOSHUA D. WARGO
............6391........... ���FSURv��v
EASEMENTENCROACHMENTS
GEORGE SHIELDS SURVEY,
ABSTRACT No. 1402
CITY OF FORT WORTH
TARRANT COUNTY, TEXAS
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EXHIBIT B
Certificate of Insurance
Tier II Easement Encroachment Agreement Page 12 of 12
Revised 12/2022
Page 1 of 1
Health Care Indemnity, Inc
2515 Park Plaza, Builiding 2-3E
Nashville, TN 37203
Health Care Phone 615-344-5193
Fax.855-775-0393
Indemnity, Inc. Email Corp.Insurance@HCAHealthcare corn
This is to certify to The City of Fort Worth
(Name of Certificate Holder) 200 Texas Street
Fort Worth, TX 76102
Certificate of Insurance
Date: 02/13/2026
COW 160541-2026
that the described insurance coverages as provided by the indicated policy has been issued to.
Named Insured. HCA Healthcare, Inc. AND SUBSIDIARY ORGANIZATIONS
Address. EXISTING NOW OR HEREAFTER CREATED OR ACQUIRED
ONE PARK PLAZA
NASHVILLE, TN 37202-0550
The Policy identified below by a policy number is in force on the date of Certificate issuance Insurance is afforded only with respect to those coverages for which
a specific limit of liability has been entered and is subject to all the terms of the Policy having reference thereto This Certificate of Insurance neither affirmatively
nor negatively amends. extends or alters the coverage afforded under any policy identified herein Coverage is excess of self-insurance Such self-insurance is
adequately funded as verified by a Fellow of the American Society of Casualty Actuaries
POLICY NO. POLICY PERIOD
Effective 1/1/2026
HCI-EX-10126-01 Expiration: 1/1/2027
TYPE OF INSURANCE
LIMITS OF LIABILITY
Comprehensive General Liability -
• Occurrence Form
• Bodily Injury
$1,000.000
Each and Every Occurrence
• Property Damage
• Products and Completed Operations
$1,000.000
Aggregate
• Personal and Advertising Injury
Health Care Professional Liability
$0
Each and Every Occurrence
Occurrence Form
$0
Aggregate
SPECIAL CONDITIONS/OTHER COVERAGES:
The Named Insured Includes: Medical City Fort Worth COID: 34318
Reference PUBLIC PROPERTY EASEMENT ENCROACHMENT LICENSE AGREEMENT — PN25-00217
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
Cancellation Should any of the above described policies be canceled before the expiration date thereof the issuing company will endeavor to mail ninety days written
notice to the above named certificate holder but failure to mail such notice shall impose no obligation or liability of any kind upon the company
Authorized Signature
FORT WORTH.
City Secretary's Office
Contract Routing & Transmittal Slip
Contractor's Name: Columbia Plaza Medical Center of Fort Worth Subsidiary, L.P.
Subject of the Agreement:
Tier II Easement Encroachment
M&C Approved by the Council? * Yes ❑ No M
If so, the M&C must be attached to the contract.
Is this an Amendment to an Existing contract? Yes ❑ No 0
If so, provide the original contract number and the amendment number.
Is the Contract "Permanent"? *Yes ❑ No 0
If unsure, see backpage for permanent contract listing.
Is this entire contract Confidential? *Yes ❑ No 0 If only specific information is
Confidential, please list what information is Confidential and the page it is located.
Certificate of Insurance
Effective Date: Date Director signs
If different from the approval date.
Expiration Date: 30 years from execution
If applicable.
Is a 1295 Form required? * Yes ❑ No ED
*If so, please ensure it is attached to the approving M&C or attached to the contract.
Project Number: If applicable.
*Did you include a Text field on the contract to add the City Secretary Contract (CSC)
number? Yes 0 No ❑
Contracts need to be routed for CSO processing in the followingorder:
rder:
1. Katherine Cenicola (Approver)
2. Jannette S. Goodall (Signer)
3. Allison Tidwell (Form Filler)
*Indicates the information is required and if the information is not provided, the contract will be
returned to the department.