2016-09-07_GENERAL DOCUMENTS - C1981035

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A(✓ �' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) I 08/29/2016 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 have ADDITIONAL INSURED provisions or 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 Aon Risk Services Southwest, inc. �w Tx office �rr� CONTACT NAME: PHONE FAX (A/C. No. Ext): (866) 283-7122 (AIC. No.): (800) 363-0105 E-MAIL ADDRESS: 5555 San Felipe`v suite 1500 � Houston Tx 77056 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURED C�` ` INSURER Zurich American Ins Co 16535 INSURER B: Zurich American Ins Co of Illinois 27855 GCC Enerqv, LLC J ` p�,�.��+" 6473 County Road 120 Hesperus Co 81326 USA �( `` �\ONS C�� INSURER C: American Zurich Ins Co 40142 INSURER D: Liberty insurance underwriters, Inc. 19917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570063464983 REVISION NUMBER: 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 Limits shown are as requested INSR LTR TYPE OF INSURANCE ADDL INSD SUBIR WVD POLICY NUMBER POLICY EFF MMIDDMMIDD POLICY EXP LIMITS C X COMMERCIAL GENERAL LIABILITY GLO EACH OCCURRENCE $2,000,000 CLAIMS-MADEX❑ OCCUR $1,000,000) PREMISETO RENTED S Ea occurrence MED EXP (Any one person) $10,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 X POLICY ❑ PRO JECT F—]LOC PRODUCTS - COMP/OP AGG $4,000,000 OTHER A AUTOMOBILE LIABILITY BAP6551242-07 09/01/2016 09/01/2017 COMBINED SINGLE LIMIT $1,000,000 Ea accident BODILY INJURY ( Per person) X ANY AUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOS NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE Per accident D X UMBRELLA LIAB X OCCUR 100005937506 09/01/2016 09/01/2017 EACH OCCURRENCE $25,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $25,000,000 DED RETENTION Products/Completed 0 $25,000,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ANY PROPRIETOR / PARTNERI EXECUTIVE N WC655124007 09/01/2016 09/01/2017X PER OTH- STATUTE ER E L EACH ACCIDENT $2,000,000 OFFICER/MEMBER EXCLUDED (Mandatory in NH) ❑ N I A E L DISEASE -EA EMPLOYEE $2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS balo� F L nicEgSF_pOLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) RE: OSM Permit CO -0106, CDRMS Permit CO -1981-035. Colorado Division of Reclamation, Mining & Safety is included as Additional Insured in accordance with the policy provisions of the General Liability policy. co co rn co 0 0 CERTIFICATE HOLDER CANCELLATION im SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Colorado Division Of Reclamation, AUTHORIZED REPRESENTATIVE Mining & Safety 1313 Sherman Street, Room 215 e Denver Co 80203 USA ' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD