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~. <br />F'RIX9 ~ : IQJi BJC' I ht~21 NG GJ <br /> <br />SB'. 8. 1995 2:32PM P 2 <br />PFIOhlE N0. 970 245 7079 <br />CEATIFICATE OF INSURANCE <br />COLORADO isc~ee py,~ <br />COMPENSATION <br />INSURANCE COLORADO COMPBNSATION INSURANCE AUTHORITY <br />TO WHOM Tf MAY CONCERN: <br />Tltit is to certify that this company has issued a Standard Workets' Compensation and Employer's liability Policy as <br />described bebw covering the liability imptuul upon subject employers by the Worlrers' Compeasafioa Act of Colorado, <br />said policy being io good standing as of this date. <br />POLICY NUMBER: 6355251 <br />POLICY PERIOD: 9-6-95 <br />INSURED: BALAZ AND ASSOCIATES INC. <br />2U3 SUNSET CIRCLE <br />PALISADE, CO 81526 <br />DATE OF ORIGINAL ISSUE: 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 />TO 9-1-96 <br />IMPORTANT: THE COVBRAGE DESCRIBED ABOVE IS IN EFFECT AS OF THE ISSUE DATE OF THIS <br />CERTIFICATE. IT [S SUBJECT TO CHANGE AT ANY TIME IN THE FIJTURE. <br />All policies are subject to the followittg provision of the Workers' Competsation Act with respect to cancellation: <br />'Ilse issuance of this certificate of insurance is subject m section 8-04.110 C.R.S. which requires that a shiny (30) <br />day entice of cancellatiou is bayed on fraud, material misrepreseotatiou, nonpayment of premium or any other <br />reason approved by dtc Commissioner of Insurancc; its such itu-tatuts, CCIA will provide a ten day notice of <br />cancellation. <br />Alteration of this document is a critnlnal offetsse pursuant to Coorado Criminal Code 1&5-103: "A person <br />comrtdts second degree forgery, if, with intent to defraud, he falsely makes, completes, alters, or utters a <br />wriltea iretrummt which is or ptuports to be, ar which is calculated to becottte or to represem~ if completed: . <br />.. a commerdal instrument..." <br />Holders of dfis certificate may contact our Customer Service Deparmten[ a[ 782-4000 to verify coverage for the <br />working classification listed on this cerdficate. <br />~Ul/~e /J/lV~t'H,~ <br />sb Steve Hurslmtan, Ctmtpensation losurancc Rcpresenrative <br />Colorado Compensation Insurance Authority • 720 S. Colorado Blvd. Sulte 100. North Tower • Denver, Colorado 80222 • (303) 782-4000 <br />Colorado Business -Our Business Sinw 1915 <br />