|
ACONRU®DATE(MMIDDNYYY)
<br />�.- CERTIFICATE OF LIABILITY INSURANCE
<br />DB,zBIZD,S
<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 />Aon Risk services southwest, Inc.
<br />Houston TX Office
<br />CONTACT
<br />NAME -
<br />;H N,, E,); (866) 283-7122 FAX N0.: (800) 363-0105
<br />5555 San Felipe
<br />Suite 1500
<br />EBUdL
<br />SSS:
<br />INSURER(S) AFFORDWO COVERAGE MAIC#
<br />Houston Tx 77056 USA
<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 />INSURER& Zurich American Ins co 16535
<br />INSURER C: Liberty Insurance Underwriters, Inc. 19917
<br />INSURER D:
<br />INSURER E:
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 570059162053
<br />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. Limits shown are as requested
<br />LTR
<br />TYPE OF INSURANCE
<br />WVD
<br />POLICY NUMBER
<br />M
<br />IMMfiXyYYYYI
<br />LIMITS
<br />X COMMERCIAL GENERAL L'ABU ITY
<br />GLO
<br />EACH OCCURRENCE $2,000,000
<br />CLAIMS -MADE x❑OCCURTEU
<br />$1,000,000
<br />PREMISES ocaumenm
<br />MED EXP (Any one Pte) $10,00
<br />PERSONAL &ADV INJURY $1,000,000
<br />GEN -L AGGREGATE LIMIT APPLIES PER
<br />GENERAL AGGREGATE $4,000,000
<br />X JET LOC
<br />POLICY ❑
<br />PRODUCTS -COMP/OP AGG $4,000,000
<br />OTHER-
<br />-B
<br />AUTOMOBILE LIABILITY
<br />BAP 6551242-06
<br />09/01/2015
<br />09/01/2016
<br />COMBINED SINGLE LIMIT $1,000,000
<br />ffA accident)
<br />BODILY INJURY ( Per person)
<br />X ANY AUTO
<br />BODILY INJURY (Peracddent)
<br />ALL OWNEDSCHEDULED
<br />AUTOS AUTOS
<br />HIREDAUTOS NON -OWNED
<br />AUTOS(Per
<br />PROPERTY DAMAGE
<br />accident
<br />$1000 Cap Dad S1DD0 Comp Dad
<br />C
<br />X
<br />UMBRELLA LUU3
<br />X
<br />OCCUR
<br />100005937505
<br />09/01/201509/01/2016
<br />EACH OCCURRENCE $25,000,000,
<br />EXCESSLIAB
<br />CLAIMS -MADE
<br />AGGREGATE $25,000,000
<br />DED RETENTION
<br />Producwcmnpleted o $25,000,000
<br />B
<br />WORKERS COMPENSATION AND
<br />EMPLOYERS' LIABLITY Y / N
<br />ANY PROPRIETOR / PARTNER / EXECUTIVE
<br />OFFICERMIEMBER EXCLUDED? N
<br />(Mandatory In NH)
<br />N I A
<br />WC 55124006
<br />0 01 201
<br />09/01/2016
<br />X PER OTH-
<br />STATUTE
<br />EJ- EACH ACCIDENT $2,000,000
<br />EL DISEASE -EA EMPLOYEE $2,000,000
<br />If yes, desrnbe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L DISEASE -POLICY LIMIT $2,000,0
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space In required)
<br />RE: OSM 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. B1 & 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 CANCELLED BEFORE THE
<br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
<br />POLICY PROVISIONS.
<br />Office of surface Mining AUTHORIMD REPRESENTATIVE
<br />Reclamation and Enforcement
<br />Western Region G _/^ 44iw. /rte
<br />1999 Broadway, Suite 3320 [%'jL[/�OYC!/C�/f ✓jr'
<br />Denver CO 80202 USA
<br />01988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />
|