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2017-02-17_REVISION - C1981035
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2017-02-17_REVISION - C1981035
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Entry Properties
Last modified
2/21/2017 8:06:06 AM
Creation date
2/21/2017 7:42:54 AM
Metadata
Fields
Template:
DRMS Permit Index
Permit No
C1981035
IBM Index Class Name
Revision
Doc Date
2/17/2017
Doc Name
Permit Renewal (King I & King II)
From
GCC Energy, LLC
To
DRMS
Type & Sequence
RN7
Email Name
RDZ
JRS
Media Type
D
Archive
No
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A� o CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MM/DD/YYYY) <br />08/29/2016 <br />I <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 have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the 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 />(A/C.NNo. Ext): (866) 283-7122 ((A No.): (800) 363-0105 <br />E-MAIL <br />ADDRESS: <br />5555 San Felipe <br />Suite 1500 <br />Houston TX 77056 USA <br />GLO 5 51 41 7 <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURED <br />INSURER A: Zurich American Ins Co 16535 <br />GCC EnerOV, LLC <br />INSURER B: Zurich American Ins Co of Illinois 27855 <br />6473 County Road 120 <br />Hesperus CO 81326 USA <br />INSURER C: American Zurich Ins Co 40142 <br />INSURER D: Liberty Insurance Underwriters, Inc. 19917 <br />INSURER E: <br />DAMAGE TO RENTED $1,000,000 <br />PREMISES Ea occurrence <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 570063465004 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 />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/DD/ <br />POLICY EXP <br />MM/DD/ <br />LIMITS <br />C <br />X COMMERCIAL GENERAL LIABILITY <br />GLO 5 51 41 7 <br />1 1 <br />7 <br />EACH OCCURRENCE $2,000,000 <br />CLAIMS-MADEX❑ OCCUR <br />DAMAGE TO RENTED $1,000,000 <br />PREMISES Ea occurrence <br />MED EXP (Any one person) $10,000 <br />PERSONAL &ADV INJURY $1,000,000 <br />GEML AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE $4,000,000 <br />X POLICY [—]PRO ❑ LOC <br />JECT <br />PRODUCTS - COMP/OP AGG $4,000,000 <br />OTHER: <br />A <br />AUTOMOBILE LIABILITY <br />BAP6551242-07 <br />09/01/201609/01/2017 <br />COMBINED SINGLE LIMIT $1,000,000 <br />Ea accident <br />BODILY INJURY ( Per person) <br />X ANY AUTO <br />BODILY INJURY (Per accident) <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />HIRED AUTOS NON -OWNED <br />ONLY AUTOS ONLY <br />PROPERTY DAMAGE <br />Per accident <br />D <br />X <br />UMBRELLA LIAB <br />X <br />OCCUR <br />100005937506 <br />09/01/2016 <br />09/01/2017 <br />EACH OCCURRENCE $25,000,000 <br />LIAB <br />CLAIMS -MADE <br />AGGREGATE $25,000,000 <br />EEXCESS <br />DED RETENTION <br />Products/Completed O $25,000,000 <br />B <br />WORKERS COMPENSATION AND <br />EMPLOYERS' LIABILITY Y / N <br />ANY PROPRIETOR/ PARTNER / EXECUTIVE <br />N <br />wc655124007 <br />09/01/2016 <br />09/01/2017X <br />PER I OTH- <br />STATUTE ER <br />E.L. EACH ACCIDENT $2,000,000 <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />N / A <br />E.L. DISEASE -EA EMPLOYEE $2,000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE -POLICY LIMIT $2,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is 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. 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 />©1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />No <br />a� <br />44 <br />W <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 <br />AUTHORIZED REPRESENTATIVE <br />Reclamation and Enforcement <br />Western Region <br />1999 Broadway, Suite 3320 <br />A <br />, <br />Denver CO 80202 USA <br />a a/n eJt/� <br />st� O <br />©1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />No <br />a� <br />44 <br />W <br />
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