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~ _i. SEP. 8.1995 2:32PM P 2 <br />FROM KLH ENGINEERING GJ PHONE N0. 970 245 7079 <br />CERTIPICATE OP INSURANCE <br />COLORADO ;u„~ yy,re <br />COMPENSATION <br />INSURANCE COLORADO COMPENSATION INSURANCE AUTHORITY <br />TO WHOM IT MAY CONCERN: <br />This U to certify that this company has issued a Standard Workers' Compensation and Employer's Liability Policy as <br />described beWw covering the liability imposed upon subject employers by me Workers' Compensation Act'of Colorado, <br />said policy being in good standing as of dtis dare. <br />POLICY NUMBER: ;1355251 <br />POLICY PERIOD: 9-6-95 TO 9-1-96 <br />INSURED: BALAZ AND ASSOCIATES INC. <br />2U3 SUNSET CIRCLE <br />PALISADE, CO 81526 <br />DATB OP ORIGiNAt JSSUE: 9-6-95 <br />DEPARTMENT OF NATURAL RESOURCES <br />ISSUED TO: DIVISION OF MINING AND GEOLOGY <br />ATTN: DAVE BERRY <br />1313 Sherman <br />Denver, CO 80221 <br />IMPORTANT: THE COVERAGE DESCRIBED ABOVE IS IN EFFECT AS OF TH8 ISSUE DATE OF THIS <br />CERTIFICATE. lT IS SUBJECT TO CHANGE AT ANY TIME !N THE FUTURE. <br />All policies are subject to dle following provision of the Workers' Compensation Act with respect to cancellation: <br />The issuance of this certificate of iacutance is subject m section 8-44.110 C.R,S. which requires that a thirty (30) <br />day mice of cancellation is bayed on fraud, material misrepresentation, nonpayment of premium or any outer <br />reason approved by tilt Commissiorer of Insurance; in such iiutances, CCIA will provide a ten day notice of <br />caixellation. <br />Alteration of this document is a criminal offeasa pursuant to Cobrado Criminal Code 18 5-103: "A person <br />commits second de~tx forgery, if, with intent to defreud, he falsely makes, completes, alters, or utters a <br />written instrument which is or ptttpotu to be, or which E calculated to become or to represent if wmpleted: . <br />.. a mmmetrJal Instrument..." <br />Holders of this certificate may contact our Customer Service Deparmient a[ 782-4000 to verify coverage for the <br />working classification listed on this certificate. <br />sh <br />iW~vE f~/lU~irtw. i <br />Steve Hurshman, Compemation losutance Represcorative <br />Colorado Compensation Insurance Authority • 720 S. Colorado Blvd. Sulte 100, North Tower • Denver, Colorado 80222 • (303) 782-4000 <br />Colorado Business -Our Business Since 1915 " <br />