2024-06-11_GENERAL DOCUMENTS - C1981022 ‎(2)‎

• Permit No: C1981022
• 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
• Email Name: LDS
• Media Type: D
• Archive: No

.44C0121::,
CS® DAT O6/3//22024YYY)
CERTIFICATE OF LIABILITY INSURANCE
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 ,z
certificate does not confer rights to the certificate holder in lieu of such endorsement(s). c
a)
PRODUCER CONTACT
AME:
Aon Risk Services Southwest, Inc. PONE FAX `-
Dallas TX office (A/C.No.Ext): [phone] (A/C.No.): [phone] v
5005 Lyndon B Johnson Freeway E-MAIL o
Suite 1500 RECEIVED ADDRESS: _
Dallas TX 75244 USA
INSURER(S)AFFORDING COVERAGE NAIL#
INSURED JUN1 72024 INSURER A: Zurich American Ins Co 16535
Oxbow Mining, LLC INSURER B:
1601 Forum Place DIVISION OF RECLAMATION
Suite 1400 INSURER C:
west Palm Beach FL 33401-8101 USA MINING AND SAFTEY INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:570106025446 REVISION NUMBER: Li
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
INSR ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER ,(MM/DD/YYYY (MM/DD/YYYY)) LIMITS
A X COMMERCIAL GENERAL LIABILITY GL0926594914 06/01/2024 06/01/2025 EACH OCCURRENCE $2,000,000
CLAIMS-MADE X OCCUR SIR applies per policy terms & conditions DAMAGE IO RENTED $1,000,000
PREMISES(Ea occurrence)
-
MED EXP(Any one person) $10,000
PERSONAL&ADV INJURY $1,000,000 r
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 N
_ POLICY JECT I X I LOC PRODUCTS-COMP/OP AGG $2,000,000 PRO- o
OTHER. G
U,
A AUTOMOBILE LIABILITY BAP 9265950 14 06/01/2024 06/01/2025 COMBINED SINGLE LIMIT $1,000,000
(Ea accident) ..
o
BODILY INJURY(Per person)
X ANY AUTO Z
OWNED —SCHEDULED BODILY INJURY(Per accident) 0)
AUTOS ONLY _ AUTOS R
X HIRED AUTOS NON-OWNED PROPERTY DAMAGE V
ONLY _AUTOS ONLY (Per accident) F
t=
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UMBRELLA LIAB OCCUR EACH OCCURRENCE U
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED RETENTION
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 yes,describe under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT —
I.
2
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
RE: Elk Creek Mine Permit #1981 - 022 Z
Y.
56
A
I- rn
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE •V,--;
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
VA Division of Reclamation AUTHORIZED REPRESENTATIVEO
Mining and Safety 3
1313 Sherman Street (� I�f� ��Q � ,p ' Q� �II
Room 215 e..�ro�a i 7.�66k c./kittaaa�e../acaL ✓s
Denver CO 80203 USA —_
MI
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