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2024-06-11_GENERAL DOCUMENTS - C1983059 (2)
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2024-06-11_GENERAL DOCUMENTS - C1983059 (2)
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Last modified
6/11/2024 10:41:16 AM
Creation date
6/11/2024 10:23:36 AM
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Template:
DRMS Permit Index
Permit No
C1983059
IBM Index Class Name
General Documents
Doc Date
6/11/2024
Doc Name
Certificate of Insurance
From
AON Risk Services
To
DRMS
Email Name
AME
LDS
Media Type
D
Archive
No
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® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/202YYYY) <br /> A D <br /> 06/03/2024 <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.If :: <br /> SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this ,°.—,' <br /> certificate does not confer rights to the certificate holder in lieu of such endorsement(s). E <br /> PRODUCER CONTACT CD <br /> NAME: <br /> Aon Risk Services Southwest, Inc. PHONE FAX •- <br /> Dallas TX Office •-t, (A/C.No.Ext): (866) 283-7122 (A/C.No.): 0800) 363-0105 y <br /> 5005 Lyndon B Johnson Freeway E-MAIL.......014% p <br /> Suite 1500ADDRESS: _ <br /> Dallas Tx 75244 USA <br /> or rs��O INSURER(S)AFFORDING COVERAGE NAIL# <br /> INSURED C5 N INSURER A: Zurich American Ins Co 16535 <br /> oxbow Energy Solutions LLC , � INSURER 4 B: American Guarantee & Liability Ins Co 26247 <br /> 1601 Forum Place P+ INSURER C: <br /> Suite 1400 \ =a ��P►'«QN <br /> West Palm Beach FL 33401-8101 USA J OI �. �CV / INSURER D: <br /> `+ `��OI ��. iPkr G INSURER E: <br /> DI-1�,1`` 01 INSURER F: �T <br /> COVERAGES CERTIPfCATE NUMBER: 570106025445 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 ADDL SUM PULICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER `MM/DD/YYYY) IMM/DD/YYY LIMITS <br /> A X COMMERCIAL GENERAL LIABILITY GL0926594914 '06/01/2024 06/01/2025 EACH OCCURRENCE $2,000,000 <br /> CLAIMS-MADE f X (OCCUR SIR applies per policy terns & conditions DAMAGE 10 REN1ED $1,000,000 <br /> PREMISES(Ea occurrence) _ <br /> MED EXP(Any one person) $10,000 <br /> PERSONAL&ADV INJURY $1,000,000 y <br /> GEN'L AGGREGATE LIMIT APPLIES PER• GENERAL AGGREGATE $4,000,000 N <br /> POLICY JEPCT n LOC PRODUCTS-COMP/OPAGG $2,000,000 0 <br /> OTHER o <br /> A BAP 9265950 14 06/01/2024 06/01/2025 COMBINED SINGLE LIMIT <br /> AUTOMOBILE LIABILITY $1,000,000 <br /> (Ea accident) .. <br /> X ANY AUTO BODILY INJURY(Per person) G <br /> _ Z <br /> OWNED —SCHEDULED BODILY INJURY(Per accident) 0) <br /> AUTOS ONLY AUTOS - iii <br /> X HIRED AUTOS NON-OWNED PROPERTY DAMAGE V <br /> ONLY AUTOS ONLY (Per accident) w <br /> t; <br /> d <br /> B X UMBRELLA LIAB X OCCUR AUC926593714 06/01/2024 06/01/2025 EACH OCCURRENCE $15,000,000 0 <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $15,000,000 <br /> DED X RETENTION$10,000 <br /> WORKERS COMPENSATION AND PER STATUTE 0TH�— <br /> EMPLOYERS'LIABILITY y/N ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E L.EACH ACCIDENT <br /> OFFICER/MEMBER EXCLUDED N/A <br /> (Mandatory in NH) E L DISEASE-EA EMPLOYEE <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT <br /> - <br /> n <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> RE: Terror Creek LLC C-1983-059 in <br /> Division of Minerals & Geology is included as an Additional Insured as required by written contract but limited to the <br /> operations of the Insured under said contract, and always subject to the policy terms, conditions and exclusions. The General 554 <br /> policy evidenced herein covers use of explosives. <br /> IS <br /> CERTIFICATE HOLDER CANCELLATION n .N.8 <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 0 1 <br /> EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE y <br /> POLICY PROVISIONS. +A <br /> ev ; Division of Minerals & Geology AUTHORIZED REPRESENTATIVE 'r- O <br /> 1313 Sherman Street r� o <br /> Room 215 war o <br /> Denver CO 80203 USA Mises imeao Y�eJn <br /> = 0 <br /> iiii <br /> ©1988-2015 ACORD CORPORATION.All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br />
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