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,~~,ae~..n,~ <br />NAME AND ADDRESS Of AGENCY <br />~eyer P,£;ency - <br />08 t.ain <br />Walsenburg, CO 81089 <br />NAME AND MAILING ADDRESS DF INSURED <br />American Fuels Inc <br />P 0 no:: 511 <br />Aguilar, Colorado 310?0 <br /> <br />COMPANY <br />~~ <br />Effective 12:Oia rn 9-7 , 19 £i3 <br />Expires g) 12:01 am ^ Noon i0-7 , 19 23 <br />^ This binder is issued to extend coverage in the above <br />company per expiring policy q <br />(er~epl as nutetl beloal <br />Description of Operation/Vehicles/Property <br />Coal :)trip I•:ine <br />1979 Chev 4:;4 PLt S,% C7:]-149F478344 <br /> Type and location of Property CoveraQelPerils/Forms Amt d Insurmnce Ded. ~` <br />P <br />R <br />0 <br />P <br />E <br />R <br />T <br />Y <br /> <br />T <br />f I <br />C <br />/F limits of Liabilit <br /> ype o <br />nsurance overage <br />orms <br /> <br />L ExhOccurrence re to <br /> <br />I ^ Scheduled form ^ Comprehensive Form Boddy In)ury $ $ <br />F ^ Premises/Operations Property <br /> O Products/Completed Operations Uamage $ $ <br /> ^ Contractual Boddy Inlury & <br />1 ^ Other (specify below) Property Damage <br />Y ^ Med. Pay. $ ver $ re, Combined <br /> l7 Personal Injury rmwn ~"~~e~t ^ A ^ B ^ C Persona l Inlury $ <br />A Limits of Liabili <br />U EJ:Liabihty ^ Non owned ^ Hired Boddy Inlury (Each Person) $ <br />7 D Comprehenswe~Deductible $ 100 Bodily Injury (Each Accident) $ <br />M 7:Colhsion-Deductible $ 250 <br />3 <br />0 . <br />^ Medical Payments $ Property Damage $ <br /> D Uninsured Motorist $ <br />B <br />I D No Fault (specify): Boddy Inlury & Property Damage <br />L ^ Other (specity): Combined $ 500,000 <br />E <br />D WORI(ERS' COMPENSATION -Statutory Limits (specrfy states below) ^ EMPLOYERS' LIABILITY -Limit $ <br />SPECIAL CONDITIONS/OTHER COVERAGES <br />NAME ANG ADDRESS Of ^ MORTGAGEE U LOSS PAYEE U ADDIINSUHEU <br />LOAN NUh".eEH <br /> <br />~~ / i <br />,~1 - --- ---- -1--- --~= <br />__.>'~, mluri• o' HuO a~i~ i1' oJ!r~,n:f,~t~.r 1'. Iy -'.de <br />1~ <br />