PERMFILE40316

• Permit No: C1981071
• IBM Index Class Name: Permit File
• Doc Date: 12/11/2001
• Section_Exhibit Name: RN APPLICATION FORMS & LETTERS
• Media Type: D
• Archive: No

.+-I://~:D. CERTIFICA OF INSURANCE 'B'"`°A'°`MM'°°""

PRODUCER ~ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE

- DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
!•_"~: ~' .;A'iFi`. L.. ?f2, t
SEL lv- POLICIES BELOW.

I'IVC' '.' ..'_ ~ ?:.; .-' .;" a COMPANIES AFFORDING COVERAGE

COMPANY A
LETTER I
I
COMPANY B _
INSURED LETTER
'- :~n'-.: :: 1. . I' it r:::,: -- ~
COMPANY ^
~,.:.I,. ~ :-.' I:.:. '' .-.. LETTER y
r'. L'.. r.:.: _. -
'
-
'
- COMPANY D ,
;.:il
ENI_L.C
.i'' .
I
. .J:~-.~ IETTER
COMPANY E
LETTER
COVERAGES
THIS IS TO CERTIFY THA77HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANV REQUI REMENT, TERM OR CONDITION OF ANV CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH TH19
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 MAV HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPC OF INSURANCC
LTR POLICY NUMBER POLICY EFFECTIVE POLICY !%PIRITION LIYITS
DATE IMMIDD/VY) PATE (MMIDDIYV)
GENERAL LIABILITY GENERAL AGGREGATE 3 `' T ~ ~ X11
C. COMMERCIAL GENERAL LIABILITY pRODUCTSJ:OMP/OP AOG. f ~f ma~, ~~r'
' I_.M CLAIMS MADE OCCUR. PERSONAL 6 ADV. INJURY f ?, amQ~, aG?IC~
A r~~OWNER'S6CONTRACTOR'BPROT. R!• b.,L i~.°•-'fS.'Y: V.IJiCI' %`i) N7/P11/'3~ EACH OCCURRENCE ~ f~aaa,avlVt
x PRCDII-):' i ,•"•~I-f.i l-I; li: FIRE DAMAGE (MYOnain) f ~~a~) avl~
~• X I ,I. I MED. IXPENSE (A,ry w peril,) f ____
AUTOMOBILE LIABILITY COMBINED BINDLE
~~
f
aa
aa
1 RR ANY AUTO LIMIT
'
L ,
a,
a
I-~ ALL OWNED AUTOB BODILY INJURY
1
A; (SCHEDULED AUTOS ~'"• (PR Perean) ~ f a
!-: ~110c:77 E Ll7/01) /iJ a7/a>. /f12
MIRED AUTOS
_ '
BODILY INJURY
f
NON~OWNED AUTOS (PSr scdEmU ~
a
GARAGE LIASILITY
--. PROPERTY DAMAGE ~ i
EXCE99 LIABILITY EACH OCCURRENCE
UMBRELLA FORM ~ ~ ~ ~ AGGREGATE f
OTHER THAN UMBRELIA FORM -~
WORKER'S COMPENSATION
' STATUTORY LIMITS
-J
EACH ACCIDENT
f
AND .. __._ _- ____.__
~ ~ Y ~ DISEASE-POLICY LIMIT ~ f -
EMPLOYERS'LIASILITY - -~----
R
DISEASE-EACH EMPLOYEE f
OTXER

DESCRIPTION OF OPERATIONS/LOCATIONSIVENICLESISPECIAL ITEMS
CYPRUS EMPIRE f:fli7P.. CV PRI'S DRCHAPDAY~IE~~T~~Pt3'~j~ C£.~~FNI~~(:OAL CO~-
INCI_. PrRMT.T al-.-Nr-Id55 + C'R, PT c9:,?~ P..rUT'1" COUi:ITY FiD. ~', OAK CREEK, CO,
CDLORf-iL0 YgMpP (;CI;11. !'J. Th1CL. M1ITNFS 1. 2. .3- PFRMTT C-Ra-V162, C-$1-a7I
CERTIFICATE HOLDER: CANCELLATION
SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
FT:~T 11 ~ '~I ~I ~ 11~' . EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
M?NE LGlidl~ F:i: G' i%•ii TTnfa ^
MAIL _ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
~PT,
_.rl. ;. ,; i_.. ;,. __ .
:. ~H LEFT, SUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
i
_
~. ~ LIABILITY OF ANV KIND UP THE COMPA Y, ITS AGENTS OR REPRESE TATIVES.
AUTXORIZED REPRESENTATIVE - ! ,
ACORD 25.5 (7/90) mACORD CORPORATION 1990