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ACORp CERT__ _ _;ATE OF LIABILITY INS 3ANCE DATE(MM1DD/YYYY) <br /> 02/17/2012 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEFL <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy{ies)must be endorsed. If SUBROGATION IS WAIVED,subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s). <br /> PRODUCER `CONTACT <br /> NAME: <br /> CIA-Leavitt Insurance Agency, Inc. ( NE No,E><tk 719.589.3611 T( c.No):800746,4434 <br /> 100 Premium Way, PO Box 5002 E-MAIL <br /> RES: <br /> Alamosa, CO 81101 PRODUCER 10000594 <br /> CUSTOMER 11,11: <br /> INSURER(S)AFFORDING COVERAGE NAIC a <br /> INSURED INSURERA: Charter Oak Fire 25615 <br /> Fuchs Ranches Inc. INSURER B: <br /> 1620 County Road 14A • INSURER C: <br /> Del Norte, CO 81132 INSURERD: <br /> INSURER E: <br /> INSURER F <br /> COVERAGES CERTIFICATE NUMBER: 11 - 12 GL REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO A L THE TERMS, <br /> EXCLUSIONS AND CONDITIONSQF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR TYPE ADDL SUER POUCYEFF POUCYEXP LtluGtS <br /> LTR INSR WVD POLICY NUMBER (MMIDD/MYYYI (MM/DD/YYYY) <br /> GENERAL LIABILITY 715373H0353IND11 07/31/2011 07/31/2012 EACH OCCURRENCE $ 1,000,000 <br /> X COMMERCIAL GENERAL LIABILITY <br /> DAMAGE TO S 50,000 <br /> PREMISES S((Ea oocurrencel <br /> CLAIMS-MADE X OCCUR MED EXP(Any one person) S 5,000 <br /> A X PERSONAL&ADV INJURY $ 1,000,000 <br /> GENERAL AGGREGATE $ 1,000,000 <br /> GEN'L AGGREGATE UMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 1,000,000 <br /> —I POLICY n JEcy n LOC $ <br /> AUTOMOmLE LIABILITY COMBINED SINGLE UMIT $ <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED AUTOS BODILY INJURY(Per accident) $ <br /> SCHEDULED AUTOS PROPERTY DAMAGE <br /> HIRED AUTOS (Per accident) $ <br /> NON-OWNED AUTOS S <br /> UMBRELLA UAB OCCUR EACH OCCURRENCE $ <br /> EXCESS UAB CLAIMS-MADE AGGREGATE $ <br /> DEDUCTIBLE $ <br /> RETENTION $ `$ <br /> WORKERS COMPENSATION WC STATU- OTH- <br /> AND EMPLOYERS'LIABIUTY YIN TORY LMITS ER <br /> ANY PROPRIETOR/PARTNER,EXECUTIVE(� N/A E.L EACH ACCIDENT $ <br /> OFFICER/MEMBER EXCLUDED? I I <br /> (Mandatory in tat) EL DISEASE-EA EMPLOYEE S <br /> If yes.descree under <br /> DESCRIPTION Oi=OPERATIONS below EL DISEASE-POLICY LIMIT $ . <br /> DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) <br /> This holder is listed on this policy as Additional Insured regarding Loc #5: Fuchs Dam & Reservoir <br /> SE 1/4 of Sec 2 & NE 1/4 Sec 11, 37N, 04E in Rio Grande County <br /> THIS CERTIFICATE IS SUB]ECT TO THE TERMS AND CONDITIONS OF THE POLICY. <br /> CERTIFICATE HOLDER CANCELLATION <br /> FAX: 303.894.2578 <br /> SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Colorado Water Conservation Board ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Ryan Edwards <br /> 1313 Sherman Street AUTHORIZEDREPRESENTArnE � <br /> Room 721 <br /> Deriver, CO 80203 Monica Espinoza/MSE <br /> ®1988-2009 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD <br />