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i~we~nena, xrsu iae~ <br />MAIL TO: <br />STATE OF COLORADO,MINERALS & GEOLOGY <br />ATTN: JIM MCARTLE <br />1313 SHERMAN ST <br />DENVER CO 80203 <br />CERTIFICATE OF INSURANCE <br />issued by the <br />COLORADO COMPENSATION INSURANCE AUTHORITY <br />111 IIIIIIIIIIIIIIII <br />sss <br />720 South Colorado Blvd, Denver, Colorado 80222, (303j 782-4000 <br />CERTIFICATE HOLDER: <br />STATE OF COLORADO,MINERALS & GEOLOGY <br />ATTN: JIM MCARTLE <br />1313 SHERMAN ST <br />DENVER CO 80203 <br />TO WHOM IT MAY CONCERN: <br />This is to certify that this company has issued a Standard Workers' Compensation and Employers' <br />Liability Policy as described below covering:the.llabillty:imposed .u pan:stifiject.employers by the <br />Workers' Compensation Act of Colorado, said policy being in good standing as.of this date. <br />POLICY NUMBER: 307829-3 <br />POLICY PERIOD:: O1/01/1996 TO 01/01/1997 <br />INSURED: J A CLARKE CORPORATION <br />P'O:BOx 293 <br />GUNNISON CO 81230 <br />ORIGINAL EFFECTIVE DATE: 02/13/1993. <br />IMPORTANT; THE COVERAGE DESCRIBED ABOVE IS IN EFFECT AS OF THE ISSUE DATE OF THIS CERTIFICATE <br />It' IS SUB:IECT TO CHANGE AT ANY TIME IN THE FUTURE. ~ ~ .~~ <br />All policies. are subject to the following provislon:of Ctie Wlirkerg'.Gompehsatlon Acf:with respect to <br />cancellation:.. <br />The issuance of:this certificate of insurance is subject to section 8-4A-.1 t0.C.R.S: which requires that a <br />thirty (30) day notlce:otcancellatlon.be given unless cancellation is.based gn fraud, material <br />misrepresentation, nonpayment of prerrlilim br. any other reason approved: by.the.Commissioner of <br />Insurance; in such instances, CCiA wiii:provide a ten daq notice .of cancellation:. <br />Alteration of this document is:a.criminal otferise pursuant to:Colorado Ciiminal Code 18-5-103: "A <br />person commits second degree forgery, if; with intent to defraud; he falsely makes;.completes, alters, <br />or utters a written instrument which is or purports to be;.or which 1s calculated.Eo become or to <br />represent i( completed: a commercial Instrument. :" <br />07/10/1996 <br />Holders of this certificate may contact our Customer Service Department at 782-4000 to verify coverage <br />for the working classification listed on the back of this certificate. <br />("SEE BACK OF CERTIFICATE FOR CLASS COVERAGE AND OWNERSHIP COVERAGE DETAIL") <br />. ..- .. .,.n ,o-uu <br />