2016-12-22_GENERAL DOCUMENTS - C1992080

• Permit No: C1992080
• IBM Index Class Name: General Documents
• Doc Date: 12/22/2016
• Doc Name: Certificate of Insurance
• From: Texas Mutual
• To: DRMS
• Permit Index Doc Type: Insurance
• Email Name: RDZ
• Email Name: JRS
• Media Type: D
• Archive: No

Texasmuta
Insurance Company
December 22, 2016
DIVISION OF RECLAMATION, MINING AND SAFE
DBA: DEPARTMENT OF NATUAL RESOURCES
1313 SHERMAN ST., ROOM 215
DENVER CO 80203
NOTICE OF CANCELLATION
Insured name and address
OAKRIDGE ENERGY INC
4613 JACKSBORO HWY
WICHITA FALLS TX 76302-2921
Material Change Holder Copy
CANCELLATION
TYPE OF POLICY:
You are hereby notified in accordance with the terms and conditions
Workers' Compensation and Employers
of the policy mentioned here, and in accordance with law, that your
Liability Coverage
insurance will cease at and from the hour and date mentioned here.
POLICY NUMBER:

POLICY PERIOD:
REASON FOR CANCELLATION
NON PAYMENT FOR INSTALLMENT BILLING
07/14/2016 to 07/14/2017
CANCELLATION TERMS
DATE OF NOTICE:
• All funds received after the date of this notice shall be retained
12/22/2016
until completion of the final audit and determination of the
earned premium for the policy.
• After the cancellation becomes effective and upon completion
CANCELLATION WILL TAKE EFFECT AT:
of the final audit, Texas Mutual will forward an invoice or a
01/25/2017 12:01 A.M.
return based on premium earned through the cancellation date.
(DATE) (HOUR -STANDARD TIME)
MESSAGES
Did you know you can pay through our online services? To make a payment online, you will need your bank account number and
routing transit number to complete your transaction. Credit card payments are not accepted.
Go to TexasMutual.com and click on payments in the employers drop down menu.
Enter your Texas Mutual online user name and password. If you are not registered, click on "New User?" or call our Information
Services Center at (800)-859-5995.
PO Box 12058, Austin, TX 78711-2058
[phone] 1 Fax [phone] texasmutual.com NTC-CANCL