GENERAL46695

• Permit No: C1981010
• IBM Index Class Name: General Documents
• Doc Date: 12/12/1991
• Doc Name: CERTIFICATE OF INSURANCE
• Permit Index Doc Type: INSURANCE
• Media Type: D
• Archive: No

~i:i~.
Sedgurick Jamas of 7N. Inc.
P. 0. BoX 1?1336
Ma aphis. Tn 35119
IMBURED
4lilliams Fork Company
P. 0. Box 137 ~,
•-Grai9 ~ - -.LO 81620/
4n`T... ~' ~ ¢. '. ~!''G~1_~.Get4'u. .1. 1......,L..~y~~1.L_1
.w..~k'1i.`kR1:~.iT': E74iJ A"~F ISSUE DATE (MM/DDIYV)
~URANC~ ~.._ ,~,
:r-:.,~-,.i.h: ,•:r:l:• V~'.:. III I II I II I II IIII III
THIS CERTIFICAT i OF INFORMATION ON4Y 'AND i
CONFERS NO RIG ggg \TE HOLDER. THIS CERTIFICATE ,
DOES NOT AMEND, CA I tNU On AL I tN I nE COVERAGE AFFORDED BY THE
POLICIES BELOW.
COMPANIES AFFORDING COVERAGE i
LETTERNY A i
radar.-a 1--L~s u r.+n cameo
I COMPANY B
LETTER ~" .~ /1 - I , i
COMPANY ~.
LETTER
LETTER Y D --- D E C D? 199
COMPANY E
LETTER
Ariined Land
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANV REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BY 7HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

WI .:y.~.,,jYPE OF INSURANCE .-~....~.•...._.. POLICY NUMBER I POLICY EFFECTIVE POLICY E%PIRATION LIYR9
.~ DATE (MMIDD/ri) ~ DATE (MM/DD/YY) ;
GEN ERAL LUVIILITY 137100018 7~)Q~Q1i 7IZJI y2: GENERAL AGGREGATE ~It ~nnnoil"
COMMERCIAL GENERAL UABILITYI i PRODUCTSCOMP/OP A00.I
QI~ n n r
T
CWMS MAD~~ OCCUfi,' ~ rPERSONAL 6 ADV. INJURY l i
n a n n r
1 fl
.OWNER'S aCONTRACTOR'S PRO'1
~ LEACH OCCURRENCE If 1nn000~i
I
.. i FIRE DAMAGE (MY one Bn) 3 ~ nIlLj ~,h .
' MED. E]CPENSE IArry an Pereanl S
n
AUT OMOBILE LIABILITY '~ COMBINED SINGLE f
ANY AUTO '~, LIMIT -
ALL OWNED AUTOS ~ I BODILY INJURY
f
9CNEDULED AUTOS (Par PeraaN
1
MIRED AUT09 I
I BODILY INJURY i f
NON-OWNEO AUTOS I
', IPer acciaenq
GARAGE LIABILITY '
PROPERTY DAMAGE
f
i
I
E%CEff LIABILITY ~ j ~~i l( LACH OCCURRENCE f
UMBRELU FORM ~ V' ~ I AGGREGATE 3
__ ~
i

' OTHER THAN UMBRELLA FORM _
~
-~ -' -
- - WORIfER'9 COYPENBATION L 1 STATUTORY LIMITS _~_"!~'="iJ -._N^-
'~ ( ~
I
~
~
"" :I 1.;
, 'I I L.
EACH ACCIDENT
f
'
.
.
+' S•= ;r.' ' "
- '~~
' ~ c,... I . ~~ YI I DISEASE-POLICY LIMIT i f
'
FAPLOYERS
LIABILITY I .~ '_""-'-" "-
DISEASE
EACH EMPLOYEE'
-
f
OTHER v,r..,,,......
.

I i

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 7HE
E%PIRATION DATE THEREOF, THE ISSUING COMPANY WILL IEN~jIEAVOFF-30 '~
'Colorado Mine Land Raclam=_tion MAILl.•DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
~~~ 1 V i S l O n A t t n: ~ Tony N a l d r O n LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR I
~~ 31 3 , 5 !~ a r m a n S t r a a t LIABILITY OF ANV KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES ~~
,Oenver~ .CO 30203 AU EDREPRE ATIVE i
~ I
~ _ I
/9 y~. AQOR_C8RP0~ ,}(0 890
_ 2- G+
;. r -.