2022-06-01_GENERAL DOCUMENTS - C1983059

• Permit No: C1983059
• IBM Index Class Name: General Documents
• Doc Date: 6/1/2022
• Doc Name: Certificate of Insurance
• From: Aon Risk Services SW
• To: DRMS
• Email Name: LDS
• Email Name: JDM
• Media Type: D
• Archive: No

DATE(MM/DD/YYYY)
A�/?0 CERTIFICATE OF LIABILITY INSURANCE I
05/23/2022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.If
SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT y
Aon Risk Services Southwest, Inc. NAME. FAX
Dallas TX Office (A/C.No.Ext): [phone] A/C.No.: [phone]
5005 Lyndon B Johnson Freeway E-MAIL 2
Suite 1500 ADDRESS:
Dallas TX 75244 USA
INSURERS)AFFORDING COVERAGE NAIC#
INSURED INSURER A: Zurich American Ins Co 16535
Oxbow Energy Solutions LLC INSURER B: American Guarantee & Liability Ins Co 26247
1601 Forum Place
Suite 1400 INSURERC:
west Palm Beach FL 3 3 401-8101 USA INSURERD:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 570093186851 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested
LTR INSIR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MWDD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY GLO EACH OCCURRENCE $2,000,000
General Liablity
CLAIMS-MADE OCCUR SIR applies per policy terns & conditions PREMISES Ea occurrence $1,000,000
MED EXP(Any one person) $10,000
PERSONAL&ADV INJURY $1,000,000
GEN'LAGGREGATELIMITAPPLIESPER. GENERAL AGGREGATE $4,000,000 ro
POLICY ❑PRO- ❑X LOC PRODUCTS-COMP/OPAGG $2,000,000 rn
0
OTHER o
n
A AUTOMOBILE LIABILITY BAP 9265950-12 06/01/2022 06/01/2023 COMBI tlED SINGLE LIMIT $1,000,000 un,
Ea accent)
BODILY INJURY(Per person) C
x ANY AUTO Z
OWNED SCHEDULED BODILY INJURY(Per accident) C!
AUTOS ONLY AUTOS W
x HIREDAUTOS NON-OWNED PROPERTYDAMAGE V
ONLY AUTOS ONLY Per accident
t
tY
B X UMBRELLA LIAB X OCCUR AUC926593712 06 O1 2022 06 01 2023 EACH OCCURRENCE 15,000,000 V
umbrella AGGREGATE $15,000,000
EXCESS LIAB CLAIMS-MADE
DED I X RETENTION SID,000
WORKERS COMPENSATION AND PER STATUTE OTH•
EMPLOYERS'LIABILITY Y/N ER
ANY PROPRIETOR/PARTNER,EXECUTIVE E L.EACH ACCIDENT
OFFICER/MEMBER EXCLUDED' ❑ N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE
If as,describe under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT
i'
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) �••�
See Attachment:
RE: Terror Creek Company. C-1983-059 RECEIVED
Ps
dUN
CERTIFICATE HOLDER ELLATION
S
DIVISION M RE SHOULD ANY OF THE ABOVE DATE THEREOF, NOTICE WILL BE DEICIES BE LIVERED IN CANCELLEDA ACCORDANCE WITH THE cc
ININGV�11\„D 1A VISIONS.
Division of Minerals & Geology AUTHORIZED REPRESENTATIVE
1313 Sherman street
Room 215 c c3 r�sGt4fc�tld c/c�d� es g
Denver CO 80203 USA
8
01988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD