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2018-03-19_REVISION - C1981022
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2018-03-19_REVISION - C1981022
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Entry Properties
Last modified
3/20/2018 11:03:00 AM
Creation date
3/20/2018 10:25:28 AM
Metadata
Fields
Template:
DRMS Permit Index
Permit No
C1981022
IBM Index Class Name
Revision
Doc Date
3/19/2018
Doc Name
Application
From
Oxbow Mining, LLC
To
DRMS
Type & Sequence
RN7
Email Name
LDS
Media Type
D
Archive
No
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-� <br />sacarrn CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MM/DDIYYYY) <br />05/30/2017 <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(les) 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, Inc of Florida <br />777 So. Flagler Drive <br />CONTACT <br />NAME: <br />(A/CC.NNo.Ext): (666) 283-7122 aC.No.: (800) 363-0105 <br />E-MAIL <br />ADDRESS: <br />suite 800 - West Tower <br />West Palm Beach FL 33401 USA <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURED <br />INSURER A: Zurich American Ins Co 16535 <br />INSURER B: <br />Oxbow Mininq, LLC <br />1601 Forum Place <br />Suite 1400 <br />INSURER C: <br />INSURER D: <br />West Palm Beach FL 33401-8101 USA <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: b/UUbbb8bb2b KLVIJIUN NUMtStI(: <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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD LIMITS <br />X I COMMERCIAL GENERAL LIABILITY GLO EACH OCCURRENCE $2,000,000 <br />CLAIMS -MADE ❑X OCCUR SIR applies per policy terns & condi ions $1,000,000 <br />PREMISES Ea occurrence <br />GEN'L AGGREGATE LIMIT APPLIES PER. <br />POLICY ❑ PRC JECT El LOC <br />OTHER <br />AUTOMOBILE LIABILITY <br />X ANY AUTO <br />OWNED SCHEDULED <br />AUTOSONLYAUTOS <br />HIREDAUTOS NON -OWNED <br />ONLY AUTOS ONLY <br />UMBRELLA LIAB OCCUR <br />EXCESS LIAB CLAIMS -MADE <br />DED RETENTION <br />WORKERS COMPENSATION AND <br />EMPLOYERS' LIABILITY Y / N <br />ANY PROPRIETOR / PARTNER / EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? N / A <br />(Mandatory in NH) <br />If yes, descnbe under <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (/ <br />RE: Elk Creek Mine Permit #1981 - 022 <br />CERTIFICATE HOLDER <br />Division Of Reclamation <br />Mining and safety <br />1313 Sherman Street <br />Room 215 <br />Denver Co 80203 USA <br />' <br />MED EXP (Any one person) $10,000 <br />PERSONAL & ADV INJURY $1,000,000 <br />GENERAL AGGREGATE $10,000,000 <br />PRODUCTS - COMP/OPAGG $2,000,000 <br />BAP 9265950-07 06/01/2017 06/01/2018 COMBINED SINGLE LIMIT $1,000, <br />Ea accident <br />BODILY INJURY ( Per person) <br />BODILY INJURY (Per accident) <br />EACH OCCURRENCE <br />AGGREGATE <br />E.L. EACH ACCIDENT <br />E.L. DISEASE -EA EMPLOYEE <br />E.L. DISEASE -POLICY LIMIT <br />, Additional Remarks Schedule, may be attached if more space is required) <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 />AUTHORIZED REPRESENTATIVE <br />t Qem c z.c//6L ✓SIA. r L'itlCtex <br />©1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />(0 <br />N <br />M) <br />U') <br />u5 <br />(O <br />0 <br />0 <br />n <br />u� <br />O <br />Z <br />r <br />V <br />w <br />41 <br />U <br />
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