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<br />A� o CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DD/YYY` )
<br />DBl2N32D,6
<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 />CONTACT
<br />NAME
<br />Aon Risk Services Southwest, Inc.
<br />Houston TX Office
<br />PHONE
<br />(866) 283-7122 FAX (800) 363-0105
<br />( Pb. Ext A!G �•
<br />5555 San Felipe
<br />Suite 1500
<br />E-MAIL
<br />ADDRESS:
<br />Houston TX 77056 USA
<br />INSURER($) AFFORDING COVERAGE NAIC $
<br />INSURED
<br />INSURER A: American Zurich Ins Co 40142
<br />GCC Energy. LLC
<br />6473 County Road 120
<br />Hesperus Co 81326 USA
<br />INSURERS: Zurich American Ins Co 16535
<br />INSURER C: Liberty Insurance Underwriters, Inc. 19917
<br />INSURER D:
<br />INSURER E:
<br />PREMISES oaurrence $1,000,000
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 570059162053 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. Limfts shown are as requesW
<br />LTR
<br />TYPE OF INSURANCE
<br />POLICY NUMBER
<br />(MI1129=1
<br />im
<br />LIMITS
<br />X COMMERCIAL GENERAL LIABRM
<br />GLO
<br />EACH OCCURRENCE $2,000,000
<br />CLAIMS -MADE OCCUR
<br />PREMISES oaurrence $1,000,000
<br />MED EXP (Any one person) $10,000
<br />PERSONAL A ADV INJURY $1,000,000
<br />GEML AGGREGATE LIMIT APPLIES PER.
<br />GENERAL AGGREGATE $4,000,000
<br />X POLICY ❑ JPERO- F -]LOC
<br />PRODUCTS - COMP/OP AGG $4,000,000
<br />OTHER.
<br />B
<br />AUTOMOBILE UASKM
<br />BAP 6551242-06
<br />09/01/2015
<br />09/01/2016
<br />COMBINED SINGLE LIMIT accident)$1,000,000
<br />BODILY INJURY ( Per person)
<br />X ANY AUTO
<br />BODILY INJURY (Per acddent)
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />HIRED AUTOS NON -OWNED
<br />AUTOS(Per
<br />PROPERTY DAMAGE
<br />accident
<br />$1000 Cog Ded $1000 Camp Dad
<br />c
<br />x
<br />UMBRELLA UAB
<br />x
<br />OCCUR
<br />100005937505
<br />09/01/2015
<br />09/01/2016
<br />EACH OCCURRENCE $25,000,000
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />AGGREGATE $25,000,000
<br />DED I RETENTION
<br />ProdudslCompleted0 $25,000,000
<br />B
<br />WORKERS COMPENSATION AND
<br />EMPLOYERS' LIABILITY Y / N
<br />ANY PROPRIETOR / PARTNER / EXECUTIVEE.L.
<br />OFFICERIMEMSER EXCLUDED? N
<br />(Mandatory in NH)
<br />N / A
<br />WC65 124006
<br />OM17717
<br />707OTrNg
<br />X I PER oTFL
<br />ST TUTS
<br />EACH ACCIDENT $2,000,000
<br />E.L. DISEASE -EA EMPLOYEE $2,000,000
<br />If yes, deacnbe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT $2,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, AddkkmW Remarks Schedule, may be attached I more apace Is required)
<br />RE: 05M Permit CO -0106A; CDRMS Permit CO -1981-035. Office of Surface mining western Regional Coordinating is included as
<br />Additional Insured in accordance with the policy provisions of the General Liability policy. BI & PD Coverage. XCU Exclusion
<br />does not apply. Coverage for explosives is included. Should any of the above described policies be cancelled before the
<br />expiration date thereof, the policy provisions will govern how notice of cancellation may be delivered to certificate holders
<br />in accordance with the policy provisions of each policy.
<br />CERTIFICATE HOLDER
<br />CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL1 E: BEFORE THE
<br />EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN ACCORDANCE WITH THE •,y
<br />POLICY PROVISIONS.
<br />office of surface mining AUTHORIZED REPRESENTATIVE
<br />Reclamation and Enforcement
<br />Western Region rill,
<br />9 Y�r� YOA � JL
<br />1999 Broadway, Suite 3320 t-(4Y®/N�i c(Ji
<br />Denver CO 80202 USA
<br />01988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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