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III'lllll'I I DATE (MWDD/YY) <br />ac//o:u. CERTIFICATE OF INSURANCE 999 9-6-94 <br />PRODUCER ~ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />Moffat Insurance A enc Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />8 y ~ HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />P.O. Box 247 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />Craig, Colorado 81626 COMPANIES AFFORDING COVERAGE <br />INSURED <br />Jay Wagner <br />Jay Wagner Construction <br />600 Hockett Circle <br />Craig, Colorado 81625 <br />COMPANY USFSG <br />A <br /> RECEIVED <br />COMPANY <br />B <br />COMPANY $EP 0819 <br />C <br />COMPANY <br />D <br />DW~s~on of n`merals a veolCgy <br />COVERAGES <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 ANV REQUIREMENT. TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BV 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 <br />CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY E%PIRATION LIMITS ' <br />LTfl DATE (MMrDOrYY) DATE (MFVDD/YY) <br />GENERAL WBILRY GENERAL AGGREGATE S 1 , 000, OOO <br />X COMMERCIAL GENERAL LIABILITY PRODUCTS COMPrOP AGG S I , OOO, OOO <br />A <br /> CLAIMS MADE X OCCUR IMP 300988347 03-20-94 03-20-95 PERSONALAADV INJURY S SOO,000 <br /> OWNER'Sd CONi PROT EACH OCCURRENCE S SOO,000 <br /> FIRE DAMAGE IAny one feel E SO , OOO <br /> MED E%P IAny one Personl 5 S , OOO <br />AUT OMOBILE LIABILITY <br /> COMBINED SINGLE LIMIT S SOG YQQD <br />A ANV AUTO <br />x ALL OWNED AUTOS <br />BODILY INJURY <br /> <br />X <br />SCHEDULED AUTOS <br />IPer person) 5 <br />X HIRED AUTOS BODILY INJURY <br /> <br />x <br />NONOWNED AUTOS 1MP300988347 <br />03-20-94 03-20-95 IPpr acoaeml S <br /> PROPERTY DAMAGE 5 <br />GARAGE LIABILITY <br />ANY AUTO <br />E%CESS LIABILnY <br />UMBRELLA FORM <br />OTHER THAN UMBRELLA FORM <br />WORKEflS COMPENSATION AND <br />EMPLOYERS' LIABILfTY <br />THE PROPRIETOR/ INCL <br />PARTNERS/E%ECUTIVE <br />OFFICERS ARE: E%CL <br />OTHER <br />AUTOONLY~EA ACCIDENT E <br />OTHER THAN AUTO ONLY <br />EACH ACCIDENT S <br />AGGREGATE S <br />EACH OCCURRENCE E <br />AGGREGATE E <br />5 <br />STATUTORY LIMITS <br />EACH ACCIDENT S <br />DISEASE POLICY LIMIT S <br />DISEASE EACH EMPLOYEE S <br />DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLES/SPECIAL ITEMS <br />All operations of the insured with respect to work performed in behalf of the certificate <br />holder. <br />CERTIFICATE HOLDER CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />DIV. OF MINES b GEOLOGY Reference: E%PIRAnoN DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL <br />State of Colorado RN Mines COal ~_ DAYS WRITTE TIDE TO TTTTTT~~~E\E\E\ CERTIFICATE HOLDER NAMED TO THE LEFT. <br />1313 Sherman Street lO 811T FAILUR AILS H NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY <br />Denver, CO 80203 ~ OF A/ KI! UPON T COMPI)INY, RS AGEMS OR REPRESEMATIVES. <br />ATTN: Erica Crosby AUI~IORIZE~EP~ESENTATIV / t <br />ACORD 25-S (3/93) \ "~T`"`aAC_ORD CORPORATION 1993 <br />