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~) <br />1 <br /> <br />1 <br /> <br />1 <br /> <br />1 <br />.1 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />~_' <br />~c+s+w <br />TRAPPER MINE, INC. <br />R~C~1V~D <br />MAR 211983 <br />WORKER' S COMPENSATION & EMPLOYER' S LIABI~h~ ~D RECLAMATION <br />_ DEPT, OF CIATURAL RESOL',^.CES <br />INSURED: Trapper Mine, Inc. <br />COVERAGE: Coverage A - To pay on behalf of the Insured all <br />obligations imposed upon the Insured by the Worker's <br />Compensation Law of the State of Colorado (including <br />occupational disease - Black Lung Benefits Act) <br />Coverage B - Defends and pays on behalf of the <br />Insured the obligations of the Insured at common <br />law for injury to or death of any employee <br />arising from such employment <br />LIMITS: Coverage A - Worker's Compensation (including <br />occupational disease) - Statutory <br />Coverage B - Employer's Liability - $100,000 <br />POLICY PERIOD: To Be Advised <br />COMPANY: Colorado State Fund (All coverages except occupational <br />disease - Black Lung) <br />Travelers Insurance Company (Black Lung Benefits) <br />ENDORSEMENTS: Federal Coal Mine Safety Act Endorsement <br />PREMIUM WORK-UP: <br />(All exposures except Black Lung Benefits) <br />W.C. <br />Code Classification Payroll Rate Premium <br />8742 Salesmen Outside $ 16,400 .60 $ 98 <br />1005 Coal Mining Surface $5,766,100 3.92 $226,031 <br />6810 Clerical Office Emp. $ 393,700 .20 $ 787 <br />,4511 Analytical Chemists $ 16,400 1.21 $ 198 <br />$227,114 <br />Black Lung Benefits <br />Estimated Standard W.C. Premium $227,114 <br />Colorado State Fund Discount (40$) $-90,862 <br />$136,252 <br />Plus Expense Constant 40 <br />Est. W. C. Total Annual Premium $136,292 <br />$6,192,600 3.27 $202,498 <br />Est. Total W. C. & Black Lung Premium $338,790 <br />