2016-10-07_REVISION - C1981025

• Permit No: C1981025
• IBM Index Class Name: Revision
• Doc Date: 10/7/2016
• Doc Name: Certificate of Insurance
• From: J. E. Stover & Associates, Inc.
• To: DRMS
• Permit Index Doc Type: Insurance
• Email Name: CCW
• Email Name: JRS
• Media Type: D
• Archive: No

DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE
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).
CONTACTPRODUCERNAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: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.
ADDL SUBRINSR POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITSPOLICY NUMBERLTR (MM/DD/YYYY) (MM/DD/YYYY)INSD WVD
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS-MADE OCCUR $PREMISES (Ea occurrence)
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $
PRO-POLICY LOC PRODUCTS - COMP/OP AGG $JECT
$OTHER:
COMBINED SINGLE LIMITAUTOMOBILE LIABILITY $(Ea accident)
BODILY INJURY (Per person) $ANY AUTO
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $HIRED AUTOS (Per accident)AUTOS
$
UMBRELLA LIAB EACH OCCURRENCE $OCCUR
EXCESS LIAB CLAIMS-MADE AGGREGATE $
$DED RETENTION $
PER OTH-WORKERS COMPENSATION STATUTE ERAND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $N / AOFFICER/MEMBER EXCLUDED?
(Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
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
© 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01)
S&BHOLD-01 BMEASE
10/6/2016
License # 0757776 Betsy Mease
HUB International Insurance Services (COL)
2742 Crossroads Blvd
Grand Junction, CO 81506
[phone] [phone]
[e-mail]
Employers Mutual Casualty Company 21415
S & B Holdings LLC
Minrec Inc
627 24 1/2 Rd Unit H
Grand Junction, CO 81505
A X 1,000,000
X X 3X6490417 09/01/2016 09/01/2017 500,000
10,000
1,000,000
2,000,000
X 2,000,000
Re: North Thompson Creek Mines, DRMS Permit C-1981-025. State of Colorado, Division of Reclamation Mining & Safety is included as an Additional
Insured. 30 days notice of cancellation is provided.
State of Colorado
Division of Reclaimation Mining & Safetly
1313 Sherman St, Rm #215
Denver, CO 80203