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AGENCY CUSTOMER ID: <br />LOC #: <br />AC40RV ® ADDITIONAL REMARKS SCHEDULE <br />Page 2 of 2 <br />PRODUCER <br />MCGRIFF, SEIBELS & WILLIAMS, INC. <br />INSURED <br />American Electric Paver Company, Inc. and all Subsidiaries <br />POLICY NUMBER <br />CARRIER <br />NAIC CODE <br />ISSUE DATE: 06!28/2018 <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: FORM TITLE: <br />(continued from previous page) <br />Notice of Cancelation: <br />Name and Address: <br />Colorado Department of Natural Resources <br />Division of Reclamation, Mining and Safety <br />1313 Sherman Street, Room 215 <br />Denver, CO 80203 <br />Number of days: 30 <br />ACORD 101 (2008101) U 2008 ACORD CORPORATION. All ngnts reservea. <br />The ACORD name and logo are registered marks of ACORD CERTIFICATE NUMBER: D8JU3N6Y <br />