GENERAL55555

• Permit No: C1981016
• IBM Index Class Name: General Documents
• Doc Date: 9/13/1994
• Doc Name: CERTIFICATE OF INSURANCE
• Permit Index Doc Type: RECLAMATION PROJECTS
• Media Type: D
• Archive: No

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CERTIFICATE OF INSURANCE
issued by the
COLORADO COMPENSATION INSURANCE AUTHORITY
720 South Colorado Blvd, Denver, Colorado 80222, [phone]
MAIL TO: CERTIFICATE HOLDER:
CO DIVISION OF MINERALS AND GEOLOGY CO DIVISION OF MINERAIS AND GEOLOGY
ATTN MAGGIE VANCLEIVE ATTN MAGGIE VANCLEIVE
1313 SHERMAN ST RM 215 1313 SHERMAN ST RM 215
DENVER CO 80203 DENVER CO 80203
TO WHOM 17 MAY CONCERN:
This is to certify that this company has issued a Standard Workers' Compensation and Employers'
Liability Policy as described below covering the liability imposed upon subject employers by the
Workers' Compensation Act of Colorado, said policy being in good standing as of this date.
POLICY NUMBER: 303160-1 09/10/1994
POLICY PERIOD: 07/01/1994 TO 07/01/1995
INSURED: JEROLD L WAGNER AND RAYMOND F WAGNER
274 CR 39
HAMILTON CO 81638
ORIGINAL EFFECTIVE DATE: 07/09/1992
IMPORTANT: THE COVERAGE DESCRIBED ABOVE IS IN EFFECT AS OF THE ISSUE DATE OF THIS CERTIFICATE
IT IS SUBJECT TO CHANGE AT ANY TIME IN THE FUTURE.
All policies are subject to the following provision of the Workers' Compensation Act with respect to
cancellation:
The issuance of this certificate of insurance is subject to section 8-44-110 C.R.S. which requires that a
thirty (30j day notice of cancellation be given unless cancellation is based on fraud, material
misrepresentation, nonpayment of premium or any other reason approved by the Commissioner of
Insurance; in such instances, CCIA will provide a ten day notice of cancellation.
Alteration of this document is a criminal offense pursuant to Colorado Criminal Code 18-x103: "A
person commits second degree forgery, if, with Intent to defraud, he falsely makes, completes, alters,
or utters a written instrument which Is or purports to be, or which is calculated to become or to
represent If completed: a commercial Instrument.
Holders of this certificate may contact our Customer Service Department at 782-4000 to verify coverage
for the working classification listed on the back of this certificate.
(''SEE BACK OF CERTIFICATE FOR CLASS COVERAGE AND OWNERSHIP COVERAGE DETAIL'')
COLORADO COMPENSATION INSURANCE A1ITHnR1Tv