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2018-02-09_REVISION - C1981044
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2018-02-09_REVISION - C1981044
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Entry Properties
Last modified
2/9/2018 9:39:16 AM
Creation date
2/9/2018 9:30:38 AM
Metadata
Fields
Template:
DRMS Permit Index
Permit No
C1981044
IBM Index Class Name
Revision
Doc Date
2/9/2018
Doc Name
Application
From
Moffat County Mining, LLC
To
DRMS
Type & Sequence
RN7
Email Name
TNL
Media Type
D
Archive
No
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Page 1 of 2 <br />A Q® <br />CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MM/DD <br />oe/2s/2017o17 <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 />CONTACT <br />NAME: <br />Willis of Tennessee, Inc. <br />c/o 26 Century Blvd <br />P.O. Box 305191 <br />PHOWC.NE FAX <br />IC No): 1-888-467-2378 <br />1-877-945-7378 AIC. <br />EMAIL <br />ADDRESS: certificates@willis.com <br />INSURERS AFFORDING COVERAGE NAIC q <br />Nashville, TN 372305191 USA <br />INSURER A: ACE American Insurance Company 22667 <br />INSURED <br />INSURER B: Underwriters at Lloyd's London 15792 <br />Peabody Energy Corporation <br />CLAIMS -MADE FX1 OCCUR <br />701 Market Street <br />INSURER C: <br />INSURER D: <br />Suite 700 <br />INSURER E <br />St. Louis, NO 631011826 <br />INSURER F: <br />A <br />COVERAGES CERTIFICATE NUMBER: W3331000 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. <br />INSR <br />LTR <br />OF INSURANCE <br />ADDLTYPE <br />JUM <br />SU p <br />POLICY NUMBER <br />EFF <br />MM/DD1YYYY <br />MMIDPOLICY <br />D//YY Y <br />LIMITS <br />Denver, CO 80203 <br />X COMMERCIALGENERALLIABILITY <br />EACH OCCURRENCE $ 2,000,000 <br />CLAIMS -MADE FX1 OCCUR <br />DAMAGE TO RENTE <br />PREMISES Eaoccuence $ 2,000,000 <br />MED EXP (Any one person) $ <br />A <br />Y <br />HDOG27870491 <br />08/01/2017 <br />08/01/2018 <br />PERSONAL BADV INJURY $ 2,000,000 <br />GENT AGGREGATE LIMIT APPLIES PER <br />GENERAL AGGREGATE $ 2,000,000 <br />POLICY ❑ PRO 17LOC <br />JECT <br />PRODUCTS-COMP/OP AGG $ 2,000,000 <br />$ <br />OTHER <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT $ <br />Ea acodent <br />BODILY INJURY (Per person) $ <br />ANY AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY (Per accident) $ <br />HIRED NON -OWNED <br />AUTOS ONLY L AUTOS ONLY <br />PROPERTY DAMAGE $ <br />Per accident <br />$ <br />B <br />X <br />UMBRELLALIAB <br />EXCESS LIAB <br />X <br />OCCUR <br />CLAIMS -MADE <br />8080117743017 <br />08/01/2017 <br />08/01/2018 <br />EACH OCCURRENCE $ 3,000,000 <br />AGGREGATE $ 3,000,000 <br />DED Fx RETENTION$ 25,000 <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY Y / N <br />ANYPROPRIETOR/PARTNER/EXECUTIVE <br />STATUTE ER <br />E L. EACH ACCIDENT $ <br />OFFICER/MEMBEREXCLUDED7 ❑N <br />/ A <br />(Mandatory in NH) <br />E.L. DISEASE - EA EMPLOYEE $ <br />E L. DISEASE - POLICY LIMIT $ <br />If yes, descnbe under <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />This Voids and Replaces Previously Issued Certificate Dated 07/27/2017 WITH ID: W3096285. <br />RE: Twentymile Coal, LLC <br />It is agreed that Colorado Division of Reclamation, Mining and Safety is included as an Additional Insured as respects <br />to General Liability where required by contract or agreement. Covers operations at Twentymile Coal, LLC including <br />CERTIFICATE HOLDER 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 />SR ID: 14988031 BATCH: 426354 <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 />AUTHORIZED REPRESENTATIVE <br />Colorado Division of Reclamation, Mining and Safety <br />1313 Sherman Street, Room 215 <br />Denver, CO 80203 <br />©1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />SR ID: 14988031 BATCH: 426354 <br />
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