2016-08-29_PERMIT FILE - C1981035A (45)

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A� �® CERTIFICATE OF LIABILITY INSURANCE °A'��rzo�'� "' 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 Aon Services Southwest, Inc. Houston TX Office CONTACT NAME: (A. NPHONEo, Ext (866) 283-7122 FAX No.I: (800) 363-0105 5555 San Felipe Suite 1500 E-MAIL ADDRESS: Houston TX 77056 USA GLO INSURERS) AFFORDING COVERAGE NAIC N INSURED INSURER A: American Zurich Ins Co 40142 GCC EnergV, LLC 6473 County Road 120 Hesperus Co 81326 USA INSURER B: Zurich American Ins Co 16535 INSURER C: Liberty Insurance underwriters, Inc. 19917 INSURER D: NSIARER E: NSURER F: MED EXP (Any aro person) $10,000 COVERAGES CERTIFICATE NUMBER: 570059161841 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 INSIR LTR TYPE OF INSURANCE yyyp POLICY NUMBER POLICY FFIF M POLICY EXP M LIMITS X COMMERCIAL GENERAL LIABILITY GLO EACH OCCURRENCE $2,000,000 CLAIMS -MADE X❑ OCCUR $1,000,000 PREMISES Es occurrence MED EXP (Any aro person) $10,000 PERSONAL &ADV INJURY 51,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 X POLICY [:] PRC- JECT ❑ LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER. B AvromoemE LIABILITY BAP 6551242-06 09/01/2015 09/01/2016 COMBINED SINGLE LIMIT $1,000,000 accident) BODILY INJURY( Per person) X ANY AUTO BODILY INJURY (Per accident) ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per acodent $1000 Coll Ded $1000 Comp Ded C X UMBRELLA LIAB x OCCUR 100005937505 09/01/2015 09/01/2016 EACH OCCURRENCE $25,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $25,000,000 DED RETENTION ProduclslCompieted 0 $2S,000,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR / PARTNER /EXECUTIVE❑ N WC 55124006 o975-1/-2 09/01/2016 X I PER OTH- STATUTE E.L.EACH ACCIDENT $2,000,000 OFFICERMiEMSER EXCLUDED? (Mandatory in NH) N I A E.L. DISEASE -EA EMPLOYEE $2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMB $2,000,005 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached K more space Is required) RE: OSM Permit CO -01061 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. CERTIFICATE HOLDER CANCELLATION it SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Colorado Division of Reclamation, AUTHORIZED REPRESENTATIVE Mining & Safety 1313 Sherman Street, Room 215 Lxon � ey. y waw Denver Co 80203 USA eJF 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD