2016-08-02_GENERAL DOCUMENTS - C2010089 (3)

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ACORIJIrCERTIFICATE OF LIABILITY INSURANCE FDATE (MM/DD/ WHICH THIS 7/28/201616 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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). PRODUCER CONTACT Lacey Skalicky Hays Companies PHONE(515)802-3006 FAX (A/C No, Ext (A/C, No): Ruan Center, 666 Grand Avenue E-MAIL ADDRESS: 17th Floor INSURER(S) AFFORDING COVERAGE NAIC p Des Moines IA 50309 INSURER A:Le_xington Insurance Company 19437 INSURER B -National Union—Fire_ Ins. Co 19445 INSURED Western Fuels -Colorado, LLC INSURER C: Email to: rklingler@tristategt.org INSURE Tri-State G&T; 1100 West 116th Ave -RD: INSURER E: Westminster CO 80234 INSURER F: COVERAGES CERTIFICATE NUMBER:2016-2017 REVISION NUMFIER: THIS IS TO CERTIFY THAT 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 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSRADDL LTR TYPE OF INSURANCE SUBR POLICY EFF POLICY EXP POLICY NUMBER MM/DD/YYYY MM/DDNYYY LIMITS X - COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A '�_ CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 021396066 8/1/2016 8/1/2017 MED EXP (Any one person) $ __ PERSONAL &ADV_ INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER _ GENERAL $ 2,000,000 X C POLICY i JE LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER Employee Benefits $ 1, 000 , 000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS _ AUTOS BODILY INJURY Per accident $ ( ) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) $ X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 25,000,000 B EXCESS LAB CLAIMS -MADE AGGREGATE $ 25, 000, 00. 0 DED X RETENTION$ 10,000 BE84160099 8/1/2016 8/1/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N __ STATUTE L -I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E L DISEASE - EA EMPLOYEE $ If yes describe under — -- - - - - DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance. -"1A I! V!ri I V_ nvwr=rc k AN%,r_LLA 1 IL)N Colorado Mined Land Reclamation Board Division of Reclamation, Mining & Safety 1313 Sherman Street, RM 215 Denver, CO 80203 ACORD 25 (2014/01) INS025 (201401) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE James Hays/TJOHNS ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD