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11M1131/1{fall /ii{i /Ia <br />MAIL TO: <br />CERTIFICATE OF INSURANCE III IIIIIIIIIIIII III <br />issued by the sss <br />COLORADO COMPENSATION INSURANCE AUTHORITY ryFC,=: <br />720 South Colorado Blvd, Denver, Colorado 80222, (303) 782-4000 FF9 \/r/~'.~ <br />C~' ~~' ~ Igo <br />STATE OF COLO. DIV. OF MINERAL & GEOLOGY <br />DEPT.NATURAL RESOURCES <br />1313 SHERMAN ST. ROOM 215 <br />DENVER CO 80203 <br />TO WHOM IT MAY CONCERN: <br />~;, ~~ <br />,,. <br />CERTIFICATE HOLDER: n~'" <br />C'~~ <br />`gi'n <br />~. <br />STATE OF COLO. DIV. OF MINERAL & GEOLOGY <br />DEPT.NATURAL RESOURCES <br />1313 SHERMAN ST. ROOM 215 <br />DENVER CO 80203 <br />This is to certify that this company has issued a Standard Workers' Compensation and Employers' <br />Liability Policy as described below covering the liability imposed upon subject employers by the <br />Workers' Compensation Act of Colorado, said policy being in good standing as of this date. <br />POLICY NUMBER: 165027-1 <br />POLICY PERIOD: 07/01/1993 TO 07/01/1994 <br />INSURED: MINERS INC DBA <br />MINERS (WESTERN) INC <br />9137 E MINERAL CIR #160 <br />ENGLEWOOD CO <br />ORIGINAL EFFECTIVE DATE: 09/06/1984 <br />01/29/1994 BROKER OF RECORD: G24782 <br />SEDGWICK JAMES OF COLORADO, INC <br />2000 SO COLORADO BLVD <br />STE 5000 <br />DENVER CO 80222 <br />(303) 691-1300 <br />80112 <br />LIMITS OF LIABILITY <br />FOR EMPLOYERS' LIABILITY COVERAGE <br />Part Two of the policy, Limit of Employers' Liability, is amended to <br />include Bodily Injury by Accident $1,000,000 each accident <br />Bodily Injury by Disease $1,000,000 each employee <br />bodily-injury-by-Ciseasa -$1,C00,000-pol icy--himit <br />(" SEE BACK OF CERTIFICATE FOR CLASS COVERAGE AND OWNERSHIP COVERAGE DETAIL ") <br />IMPORTANT: THE COVERAGE DESCRIBED ABOVE IS IN EFFECT AS OF THE ISSUE DATE OF THIS CERTIFICATE. IT IS <br />SUBJECT TO CHANGE AT ANY TIME IN THE FUTURE. <br />All policies are subject to the following provision of the Workers' Compensation Act with respect to <br />cancellation: <br />Section 8-45-113. If any employer shall be in arrears for more than thirty days in any payment required <br />to be made by him to the Colorado Compensation Insurance Authority as provided by this Act, he <br />shall by virtue of such arrearage be in default of such payment and any policy issued to him by said <br />Authority shall thereupon be cancelled without notice as of the effective date or renewal date of said <br />policy. <br />COLORADO COMPENSATION INSURANCE AUTHORITY <br />ImE rua {03 mriai ¢m <iul iati{a <br />UPDATED 02/92 P2b7-Ol <br />