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AGENCY CUSTOMER ID: 10529717 <br />AC ® LOC #: <br />v ADDITIONAL REMARKS SCHEDULE Page _ of _ <br />AGENCY <br />Aon Risk Services Southwest, Inc. <br />NAMEDINSURED <br />GCC Energy, LLC <br />POLICY NUMBER <br />See Certificate Number: 570055459613 <br />CARRIER <br />Pee Certificate Number: 570055459613 <br />N <br />EFFECTIVE DATE <br />ADDITIONAL REMARKS <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance <br />Additional Description of Operations / Locations / Vehides <br />Re: OsM Permit CO -0106; CDRMS Permit CO- 1981 -035. <br />Colorado Division of Reclamation, Mining & safety is named as an Additional Insured as required by written <br />contract but limited to the operations of the Insured under said contract, and always subject to the policy <br />terms, conditions and exclusions. <br />ACORD 101 (2008101) ® 2008 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />