2011-06-03_GENERAL DOCUMENTS - C1981038

• Permit No: C1981038
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 6/3/2011
• Doc Name: Certificate of Liability
• To: DRMS
• Permit Index Doc Type: Insurance
• Email Name: JJD
• Email Name: SB1
• Media Type: D
• Archive: No

166513001
A R V CERTIFICATE OF LIABILITY INSURANCE DA 5/27N/2IDDIYYYY)
011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poilcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT
Commercial Lines - [phone] NAME: FAX
PHONE A/C No
Wells Fargo Insurance Services of West Virginia Inc. No. EXQ;
ADDRESS:
41 Eagles Road INSURERS AFFORDING COVERAGE NAIC #
Beckley, WV 25801-3643 INSURER A: National Union Fire Ins. Co. of Pittsburgh, PA 19445
INSURED Bowie Resources, LLC INSURER B :
PO Box 5057 INSURER C :
INSURER D :
INSURER E :
Ashland, KY 41105 INSURER F :
----•-.----... ..__-_ o4n•IOCn nC\/IQIA\I\111¦IIQCC. C-... 1...1..,.•
V V Y GRI1 V GJ
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

ILTR
TYPE OF INSURANCE ADDL SUER
POLICY NUMBER
POLICY MM/DD/Y EFF YYY
)

POLICY EXP
NYYYI
LM

LIMITS
GENERAL LIABILITY EP'CHOCCURRENCE $ 2,000,000
A 6464602 5/31/11 5/31/12
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 1,000.000
MADE a OCCUR
CLAIMS MED EXP (Any one person) $ 10,000
X -
Blastin
& XCU PERSONAL & ADV INJURY $ 2,000,000
g GENERAL AGGREGATE $ 3,000,000
'L AGGREGATE LIMIT APPLIES PER: ?eV PRODUCTS - COMP/OP AGG $ 2,000,000
GEN ? $
X POLICY PRO LOC
AUTOMOBILE LIABILITY
O COMBI ED SINGLE LIMIT
Ea accident
Ok m
oo

ANY AUTO N
< C
ke*J BODILY INJURY (Per person) $
t a
S $
ALL OWNED SCHEDULED `Jt\
`
, d BODILY INJURY (Per accident)
AUTOS AUTOS
NON-OWNED S a
\v\
\)0\5
?ng PROPERTY DAMAGE
$
HIRED AUTOS P Peraccdent
AUTOS
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $

EXCESS LIAB CLAIMS-MADE AGGREGATE $

DED RETENTION $ $
WC STA U- OTH-
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
?
OFFICER/MEMBER EXCLUDED?
in NH)
(Mandator NIA

E.L. DISEASE - EA EMPLOYE

$
y
If yes, describe under
DISEASE - POLICY LIMIT
L
E
$
DESCRIPTION OF OPERATIONS below .
.

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
Evidence of Insurance as respects to Bowie #1 Mine Permit #C-1981-038. General Liability Policy provides protection for use of explosives.
V CRI Ir llrMl C r7V LN GR ?• •'???-• ••'-"
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
State of Colorado Dept. of Natural Resources THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Divsion of Minerals & Geology
1313 Sherman Street, Room 215 AUTHORIZED REPRESENTATIVE
Denver, CO 80203
I ne AUUKU name ana Togo are regi5tereu mains ul -wnu v • owe-?.Y .Y r...v...+ ...?•?• ..•..? • •-•-• • ••• • •a••__ . ___.
ACORD 25 (2010/05)