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Job Na. 5712 <br />sss IFICATE OF INSURANCE -WORKMEN'S COMPENSATION & LIABILITY ONLY ~`~~I.sr~ ,~~ <br />This certificate is issued as a matter nl information only and confers no rights upon the certificate holder. Thls certificate does pp},amend, t <br />extend or alter the coverage afforded by the policies listed below. L/~ e 3 O ~~ <br />Project Permit for Grassy Creek Coal Mining, Routh G4,4il~gty, Colorado <br />Owner o ora o epar men o aura esources, ~7ne an ec ama ion ivision, <br />Contractor erman see , enver, <br />Architect/Engineer <br />of <br /> <br />ggent (,ODD, ~trecKer, uunphY ~ [lminermann , Inc. Address2 702 Interna tional Lane. Madison. WI 53704 <br />WORKMEN'S COMPENSATION: <br />Policy No. WC70 024 31 77 Effective 12/20/85 Expiration 12/20/86 <br />Insurance Company ~ Transoorta tion Insurance Company Address Milwaukee, Wisconsin <br />Coverage -Workmen's Compensation, Statutory. Employer' s Liability Limit $ 100, 000./$50 0, 000./$100, OOO.each acadent <br />PUBLIC LIABILITY: <br />Policy No. CCP~D 024 31 78 Effective 12/20/85 Expiration 12/20/86 <br />Insurance Company Transportation Insurance C ompany Address Milwaukee, Wisconsin <br />Type of Polley: ®Comprehensive ^Other <br />LIMITS: <br />Bodily Injury $ Each Occurrence Property Damage $ Each Occurrence <br />Personal Injury <br />Aggregate <br />Aggregate <br />COVERAGE PROVIDED (Check Applicable Spuarel: <br />Operations of Contractor <br />Operations of Sub~Contractor Icontingentl <br />Does Personal Injury include claims <br />related to employment? <br />Completed Operations/Products <br />Contractual Liability (broad form) <br />Exceptions: <br />AUTOMOBILE LIABI LITV <br />S Aggregate <br /> -OR - <br /> CombinedSingleLimit E 500,000. Each Occurrence <br />Yes No Yes No <br />© ^ Governmental Immunity is waived ^ <br />® ^ Property Damage liability includes: <br /> Damage due to blasting ~ ^ <br />® ^ ~ Damage due to collapse ® ^ <br />® ^ Damage to underground facilities © ^ <br />® ^ Broad Form Property damage ® ^ <br />Policy No. fsUA30 024 31 79 Effective 12/20/85 Expiration 12/20/86 <br />Insurance Company Transoor tation Incuranr•a o , a ~- Address Milwaukee. W, srbnc; n <br />Type of Policy: ®Comprehensive ^Other <br />LIMITS: <br />Bodily Injury: S Each Person - OR - <br />S Each Occurrence Combined Single Limit $ 500, 000. Each Occurrence <br />Property Damage $ Each Occurrence <br />Yes No <br />Coverage is provided }or operation of all owned, hired and non-owned vehicles ® ^ <br />UMBRELLA EXCESS LIABILITY INCLUDING AUTOMOBILE LIA81_LITY: <br />Policy No. Effective Expiration <br />Insurance Company Address <br />LIMITS: <br />Single Limit Bodily Injury <br />and Property Damage $ <br />Each Occurrence <br />Yes No <br />COVERAGE PROVIDED: Applies in excess of the coverages listed above for Employer's liability, Public Liability <br />and Automobile Liability SUBJECT TO THE TERMS OF THE POLICY. ^ ^ <br />Are any deductibles applicable to bodily injury or property damage on any of the above coverages? If so, list. ^ <br />AGENT CARRIES ERRORS AND OMISSIONS INSURANCE © ^ <br />S u~ldt^L2nyy ~~Jts)~ above described policies be cancelled before the expiration date thereof, the issuing company will pHk7PMKXE( mail <br />~X~t'Cf)K Qays ~~it(en notice to the Ofe'fd1(M~IOtlrcertifitate holder, but failure to mail such notice shall impose no obligation or liability oT <br />any kind upon the company <br />Madison, Wisconsin December 26, 1985 <br />Dated at on By <br />Authorised Insurance Representative <br />Conftruction Industry Cpope.ative Commitree of Minnesota -Form C.I.C.C.-701, Feb. 1961, Rev. June 1%B, Rev. Jan 1971, Rev. Nov. 1977 <br />Vrinted by H. A. Roar, Cp., 7727 Wayzata Blvd., Mpls., 55405, 7774870 <br />