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2016-07-18_REVISION - C1981008 (2)
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2016-07-18_REVISION - C1981008 (2)
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Entry Properties
Last modified
8/24/2016 6:24:55 PM
Creation date
7/25/2016 6:52:04 AM
Metadata
Fields
Template:
DRMS Permit Index
Permit No
C1981008
IBM Index Class Name
Revision
Doc Date
7/18/2016
Doc Name
Application
From
Tri-State Generation and Transmission Association, Inc
To
DRMS
Type & Sequence
SO2
Email Name
BFB
DIH
Media Type
D
Archive
No
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ACORO0 <br />C" CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MM/DD/YYYY) <br />7/30/2015 <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 HOLDER. <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 <br />Hays Companies <br />Ruan Center, 666 Grand Avenue <br />17th Floor <br />Des Moines IA 50309 <br />CONTACT LdC@ SkaliCk <br />NAME: y y <br />PHONE (515)802-300 6 FAC No: <br />E-MAIL <br />ADDRESS: <br />INSURERS AFFORDING COVERAGE NAIC # <br />INSURER A.-Lexin ton Insurance Company <br />INSURED <br />Elk Ridge Mining and Reclamation <br />1100 West 116th Ave <br />Westminster CO 80234 <br />INSURER B :National Union Fire Ins. Co <br />INSURER C : <br />INSURER D: <br />INSURER E: <br />INSURER F : <br />COVERAGES CERTIFICATE NUMBER:2015 - 2016 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 CONDITION 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 ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />OF INSURANCE <br />ADDLTYPE <br />INSR <br />WVD SUER <br />POLICY NUMBER <br />POLICY EFF <br />POLICY <br />LIMITS <br />AUTHORIZED REPRESENTATIVE <br />GENERAL LIABILITY <br />James Hays/ANAPOL <br />EACH OCCURRENCE $ 1,000,000 <br />X COMMERCIAL GENERAL LIABILITY <br />DAMAGE TO RENTED 100 000 <br />PREMISES Ea occurrence $ r <br />A <br />CLAIMS -MADE Fx_] OCCUR <br />021396066 <br />8/1/2015 <br />/1/2016 <br />MED EXP (Any one person) $ <br />PERSONAL & ADV INJURY $ 1,000,000 <br />GENERAL AGGREGATE $ 2,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER <br />PRODUCTS - COMP/OP AGG $ 2,000,000 <br />$ <br />POLICY PRO X LOC <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident <br />BODILY INJURY (Per person) $ <br />ANY AUTO <br />BODILY INJURY (Per accident) $ <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />PROPERTY DAMAGE $ <br />Per accident <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />X <br />UMBRELLA LIAB <br />X <br />OCCUR <br />EACH OCCURRENCE $ 25,000,000 <br />AGGREGATE $ 25,000,000 <br />B <br />EXCESS LIAB <br />CLAIMS -MADE <br />DED X RETENTION$ $10100 <br />$ <br />E84160099 <br />/1/2015 <br />/1/2016 <br />WORKERS COMPENSATION <br />WC STATULIMIT- OTH- <br />ITOR ER <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N <br />E L EACH ACCIDENT $ <br />OFFICERIMEMBER EXCLUDED? ❑ <br />N / A <br />(Mandatory in NH) <br />E L DISEASE - EA EMPLOYE $ <br />E.L DISEASE -POLICY LIMIT $ <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) <br />Evidence of insurance as respects New Horizon North Mine in Nucla, CO (Permit #C-2010-089) and New <br />Horizon Mine (Permit #C-81-008). Includes explosives. <br />CFRTIFICATF HnLDFR CANCELLATION <br />ACORD 25 (2010/05) <br />INS025 i2nlnn-it n1 <br />©1988-2010 ACORD CORPORATION. All rights reserved. <br />Tho Arnpn mama and Innn ara ranictararl marlrc of a( npn <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Colorado Mined Land Reclamation Board <br />Division of Reclamation, Mining & Safety <br />1313 Sherman Street, RM 215 <br />AUTHORIZED REPRESENTATIVE <br />Denver, CO 80203 <br />James Hays/ANAPOL <br />ACORD 25 (2010/05) <br />INS025 i2nlnn-it n1 <br />©1988-2010 ACORD CORPORATION. All rights reserved. <br />Tho Arnpn mama and Innn ara ranictararl marlrc of a( npn <br />
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