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~ Form20.102-CSO ~ Professional Provider Insurance 1:.,.... (5/2002) -... Page 1 of 2 ", r,.,..,..,..." The named contractor shall not commence work until he/she has obtained the minimum insurance specified in Section II, below. The contractor must obtain the following endorsements: the Texas Department of Transportation as an Additional Insured for policies 3 and 4, and a Waiver of Subrogation in favor of the same department under policies 2, 3 and 4. Only certificates of insurance published by this department are acceptable as proof of insurance. Commercial carriers' certificates are unacceptable. CERTIFICATE OF INSURANCE NOTE: Copies of the endorsements listed below are not required as attachments to this certificate. 1.1 Insured Contractor's Name City of San Marcos SECTION I . IDENTIFICATION DATA 1.2 StreeVMailing Address 630 E Hopkins 1.3 City San Marcos 1.4 State TX 1.5 Zip 786 6-6300 CITY OF SAN MARCOS HUMAN RESOURCES 1.6. Phone Number Area Code ( 512 ) 1.7 Vendor Identification Number 393-8060 Ext. SECTION II . TYPE OF INSURANCE Type Policy Number: Effective Date: Expiration Date: Limits of Liability Not Less Than' 2. WORKERS' COMPENSATION 2.1 8475 2.2 1 % 1/2005 2.3 10/01/2006 Statutory - Texas 4. $325,000 combined single limit each occurrence and in the aggregate Endorsed with the Texas Department of Transportation as an Additional Insured and endorsed with a Waiver of Subrogation in favor of the Texas Department of Transportation. TEXAS BUSINESS AUTOMOBILE POLICY A. Bodily Injury 4.1 8475 Endorsed with a Waiver of Subrogation in favor of the Texas Department of Transportation. COMMERCIAL GENERAL LIABILITY Bodily Injury/Property 3.1 8475 Damage 3.2 10/01/2005 3.3 10/01/2006 3. I $100,000 ea. person $300,000 ea. occurrence B. Property Damage 4.4 8475 4.5 10/01/2005 4.6 10/01/2006 $25,000 ea. occurrence Endorsed with the Texas Department of Transportation as an Additional Insured and endorsed with a Waiver of Subrogation in favor of the Texas Department of Transportation. UMBRELLA POLICY (If Applicable) 5.1 N/A 4.2 10/01/2005 4.3 10/01/2006 5. 5.2 5.3 $ SECTION III - CERTIFICATION This Certificate of Insurance neither affirmatively or negatively amends, extends, or alters the coverage afforded by the above insurance policies issued by the insurance company named below. Cancellation of the insurance policies shall not be made until THIRTY DAYS AFTER the undersigned agent or his/her company has sent written notices by certified mail to the contractor and the Texas Department of Transportation. THIS IS TO CERTIFY that the insurance policies above meet all the requirements stipulated above and such policies are in full force and effect. If this form is sent by facsimile machine (fax). the sender adopts the document received by TxDOT as a duplicate original and adopts the signature produced by the receiving fax machine as the sender's original signature. The Texas Department of Transportation maintains the Information collected through this form. With few exceptions, you are entiUed on request to be informed about the information that we collect about you. Under sections 555.021 and 553.023 of the Texas Govemment Code, you also are entiUed to receive and review the information. Under section 559.004 of the Government Code, you are also entitled to have us correct information about you that is incorrect. Authorized Agent's Phone No. Area Code (800)537-6655 Ext. 328 6.5 Zip 78714-9194 7.1 Name of Authorized Agent Paula Marr-Ludwig, Senior Underwriter 7.2 Agent's Address PO Box 149194 7.3 City State Austin 7.5 Zip 78714-9194 6.1 Name of Insurance Texas Municipal League-Intergovernmental Risk Pool 6.2 Company Add ress PO Box 149194 6.3 City :tf/ I JOG uate