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ACORD.. CERTIFICATE OF LIABILITY INSURANCE 09/30/2005 09/29/2004
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Lockton Companies ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
444 W.47th Street,Suite 900 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Kansas City Mo 64112-1906 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
(816)960-9000 INSURERS AFFORDING COVERAGE
INSURED US CABLE OF COASTAL-TEXAS L.P. INSURER A HARTFORD FIRE
4333 dba US CABLE OF WEST TEXAS INSURER B: HARTFORD CASUALTY
28 WEST GRAND AVENUE INSURER C: FIREMAN'S FUND
MONTVALE NJ 07645 IN XI n COMMERCE&INDUSTRY (AIG-ST.LOUIS)
I NSURFRE- INS. CO OF STATE PA(AIG-ST.LOUIS)
COVERAGES USCABO3 ZB
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICY EFFECTIVE POLICY EXPIRATION
ITR TYPE OF INSURANCE POLICY NUMBER DATEIMMIDDM/I DATEIMM/DD/YYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X COMMERCIAL GENERAL LIABILITY 37UUNAK0159 09/30/2004 09/30/2005 FIRE DAMAGE(My one fire) $ 300,000
I CLAIMS MADE X OCCUR MED EXP(My one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000
POLICY PEMLQT PI LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
A X ANY AUTO 37UENAK0228(AOS) 09/30/2004 09/30/2005 (Ea accident)
B ALL OWNED AUTOS 37UENAK0238(TX) BODILY INJURY $ XXXXXXX
SCHEDULED AUTOS (Per person)
X HIRED AUTOS BODILY INJURY $ XXXXXXX
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $ XXXXXXX
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ XXXXXXX
MW AUTO NOT APPLICABLE OTHER THAN EA ACC $ XXXXXXX
AUTO ONLY: AGG $ XXXXXXX
EXCESS LIABILITY EACH OCCURRENCE $ 5,000,000
C X I OCCUR CLAIMS MADE XYM8643-7316 09/30/2004 09/30/2005 AGGREGATE $ 5,000,000
g XXXXXXX
In UMBRELLA
DEDUCTIBLE I I FORM s XXXXXXX
RETENTION $ $ XXXXXXX
WC TATU 0TH-
D WORKERS COMPENSATION AND 328-39-98(AOS) 09/30/2004 09/30/2005 X ITDRY LIMITS FR
E EMPLOYERS'LIABILITY 328-39-99(NJ) 09/30/2004 09/30/2005 E.L.EACH ACCIDENT $ 1,000,000
E.L.DISEASE-EA EMPLOYEE $ 1,000,000
E.L.DISEASE-POLICY LIMIT $ 1,000,000
A OTHER 37UUNAK0159 09/30/2004 09/30/2005 ALL RISK FORM.$10,000 DED.
REAL&PERSONAL PROPERTY
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER IS AN ADDITIONAL INSURED UNDER THE ABOVE CAPTIONED POLICY.
CERTIFICATE HOLDER ADDITIONAL INSURED:INSURER LETTER: - :ANCFI I ATION
1003184 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
WELD COUNTY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _--- DAYS WRITTEN
ATTN:BILL HAWKINS NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
P.O.BOX 758
GREELEY CO 80632 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES. ^�
AUTHORIZED REPRESENTATIVE
ACORD 25-S(7197) For questions regarding this certificate,contact the number listed in the'Producer section above, 1CORD C PORATION 1988
(10rrirnu.✓t(19/rsi✓ (14 : co 2004-3041 ego i0-- // -Gy
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACUKU 2b-b(UV()
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