2010-07-06_GENERAL DOCUMENTS - C1980003

• Permit No: C1980003
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 7/6/2010
• Doc Name: Certificate of Liability Insurance
• Permit Index Doc Type: Insurance
• Email Name: JDM
• Media Type: D
• Archive: No

Av Ua CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDlYYYY)
06/29/2010
PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION
Marsh USA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1166 Avenue of the Americas HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
New York, NY 10036-2774 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Attn: [e-mail] Fax: [phone]
008046-ALL-cas- 10- 11 ® INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: Hartford Fire Insurance Co 19682
GRACE $ CO
W
R
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.
.
.
aW>
7500 GRACE DRIVE INSURER B: N/A N/A
COLUMBIA, MD 21044 INSURERC:

INSURER D:

INSURER E:
CnVFRAr.FS `'
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE
MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND
CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NS ADD' TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION LIMITS
LTR INSR DATE(MM/DD/YYYY) DATE(MM/DD/YYYY)
GENERAL LIABILITY SELF INSURED 06/30/2010 06/30/2011 EACH OCCURRENCE 5,000,000
DAMAGE TO RENTED 5
000
000
COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence $
,
,
F
] MED EXP (Any one person) $ EXCLUDED
CLAIMS MADE
L
OCCUR
X SELF-INSURED PERSONAL BADV INJURY $ 5,000,000

W. R. GRACE & CO GENERAL AGGREGATE $
GENERAL AGGREGATE LIMIT APPLIES PER
PRO-
- PRODUCTS - COMP/OP AG
POLICY JECT 1
1 LOC
A AUT OMOBILE LIABILITY 10 CSE C47908 06/30/2010 06/30/2011
COMBINED SINGLE LIMIT
$ 2,000,000
X ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)

HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE
(Per accident)
$

GA RAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: $
AGG
EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR F-? CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $
WORKER S COMPENSATION AND
' X WC STATU. OTH-
EMPLOYERS
LIABILITY SEE ADDITIONAL PAGE
000
000
$ 2
ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N .L. EACH ACCIDENT ,
,
OFFICER/MEMBER EXCLUDED?
.L. DISEASE - EA EMPLOYE
$ 2,000,000
(Mandatory in NH) If yes, describe under
L. DISEASE -POLICY LIMIT
$ 2,000,000
SPECIAL PROVISIONS below
OTHER - -- -
DESCRIPTION OF OPERATIONSlLOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
The coverage and limits stated above apply to Permit #C80-003
CERTIFICATE HOLDER NYC-003677526-19 CANCELLATION
Colorado Division of Minerals and
Geology
Attn: Jim Stark
1313 Sherman Street - Room 215
Denver, CO 80203
ACORD 25 (2009/01)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND
UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
Dresa Allman
@ 1998-2009 ACORD CORPORATION. All Rights Reserved
The ACORD name and logo are registered marks of ACORD