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2016-10-28_REVISION - C1981028
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2016-10-28_REVISION - C1981028
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Entry Properties
Last modified
11/2/2016 8:58:06 AM
Creation date
10/28/2016 9:56:28 AM
Metadata
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Template:
DRMS Permit Index
Permit No
C1981028
IBM Index Class Name
Revision
Doc Date
10/28/2016
Doc Name
Application
From
Coors Energy Company
To
DRMS
Type & Sequence
RN7
Email Name
TNL
DIH
Media Type
D
Archive
No
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A � Q® <br />CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MMIDDIYYYY) <br />l`('nC/J/%� <br />11/1/2016 <br />10/30/2015 <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(les) 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 Lockton Companies <br />CONTACT <br />NAME: <br />PHONE FAX <br />AIC No Ext : JAIC, No): <br />8110 E Union Avenue <br />E-MAIL <br />Suite 700 <br />Denver CO 80237 <br />ADDRESS: <br />X 5100.000 SIR <br />(303) 414-6000 <br />INSURERS AFFORDING COVERAGE NAIC # <br />INSURER A: ACE American Insurance Company 22667 <br />PRODUCTS - COMP/OP AGG $ 2,000,000 <br />INSURED Molson Coors Brewing Company <br />INSURER B : <br />INSURER C : <br />1030130 Coors Energy Company <br />INSURER D : <br />1801 California Street, Suite 4700 <br />INSURER E: <br />Denver, CO 80202 <br />INSURER F: <br />BODILY INJURY (Per person) $ XXXXXXX <br />COVERAGES MOLCO M CERTIFICATE NUMBER: 1419971 REVISION NUMBER: XXXXXXX <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 <br />ILTR <br />TYPE OF INSURANCE <br />ADDL <br />SUBR <br />POLICY NUMBER <br />POLICY EFF <br />MM/DD/YYYY <br />POLICY EXP <br />MM/DDIYYYY <br />LIMITS <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE OCCUR <br />X Vendors <br />N <br />N <br />OGLG25700983 <br />11/1/2015 <br />11/1/2016 <br />EACH OCCURRENCE $ 21000,000 <br />PREMISEDAMAC�ES EaEoccu r Oce $ XXXXXXX <br />MED EXP (Any one person) $ 5,000 <br />X 5100.000 SIR <br />PERSONAL & ADV INJURY $ 2,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER <br />POLICY ❑ PRO - <br />POLICY ❑ LOC <br />OTHER <br />GENERAL AGGREGATE $ 2,000,000 <br />PRODUCTS - COMP/OP AGG $ 2,000,000 <br />$ <br />A <br />AUTOMOBILE LIABILITY <br />X ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />NON -OWNED <br />X HIRED AUTOS X AUTOS <br />N <br />N <br />CALH08610319 <br />11/1/2015 <br />11/1/2016 <br />COMBINED SINGLE LIMIT <br />dent 2,000,000 <br />Ea accident <br />BODILY INJURY (Per person) $ XXXXXXX <br />BODILY INJURY (Per accident) $ XXXXXXX <br />PROPERTY DAMAGE $XXXXXXX <br />Per accident <br />$XXXXXXX <br />UMBRELLA LIAB <br />EXCESS LIAB <br />OCCUR <br />CLAIMS -MADE <br />NOT APPLICABLE <br />EACH OCCURRENCE $ XXXXXXX <br />AGGREGATE $ XXXXXXX <br />DED I I RETENTION $ <br />$ XXXXXXX <br />WORKERS COMPENSATIONPER <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />NIA <br />NOT APPLICABLE <br />STATUTE EORH <br />E L EACH ACCIDENT $ XXXXXXX <br />EL DISEASE - EA EMPLOYEE $ XXXXXXX <br />E L DISEASE -POLICY LIMIT $XXXXXXX <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />RE Keenesburg Mine <br />CERTIFICATE HOLDER CANCELLATION <br />1439971 <br />Colorado Division of Reclamation <br />Mining d Safety <br />g any <br />1313 Sherman Street, Room #215 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Denver CO 80203 <br />AUTHORIZED REPRES A E <br />(X�IC <br />ACORD 26 (2014/01) <br />©1988 7014 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />
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