Laserfiche WebLink
Pager 2 of Z <br />IMPORTANT <br />if dre certificate holder is an ADDiT70NAL INSURED, the poficy(ies) must be endorsed. A statement <br />on this certificate does not confer rights to the certificate holder in Iteu of such endorsement(s). <br />Ii SUBROGATION IS WANED, subject to the terms entl tnrrdhbns of the policy, certain policies may <br />require an endorsement A statement on this cerUfrtafe does not tooter rights to the certificate <br />holder in lieu of such endorsement(s). <br />OfSCU11MER <br />The Certificate of Insurence on the reverse side of this form does not wnstitule a wnlrauY between <br />the issuing insurer(s), authorized representagve or producer, and the certificate holder, nor does it <br />affirmatively or negatively amend, extend or aNer the coverage aftorded by the poicies listed thereon. <br />RECEIVED <br />OCT 18 2005 <br />Division o/Minerals and Geology <br />Co11:1417311 11:417397 Cect <br />