2011-06-17_GENERAL DOCUMENTS - C1981022

• Permit No: C1981022
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 6/17/2011
• Doc Name: Certificate of Liability
• To: DRMS
• Permit Index Doc Type: Insurance
• Email Name: MPB
• Email Name: SB1
• Media Type: D
• Archive: No

A?O'RD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
06/06/2011
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 policy(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
AME
N:
ADn Risk Services, Inc of Florida [phone]
[phone]
A
C.
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222 Lakeview Avenue /
(A/C
.
No. Ext):
. No.):
(A
Suite 510 E-MAIL
west Palm Beach FL 33401 USA ADDRESS:
O INSURER(S) AFFORDING COVERAGE NAIC #
INSURED INSURER A: Zurich American Ins Co 16535
Oxbow Mining, LLC
1601 Forum Place

1

INSURER B:
Suite 1400 11 'L0?
O INSURER C:
west Palm Beach FL 33401-8101 USA a u
1, ?EG``ln ??? INSURER D:
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i(1?n9 INSURER F:
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COVERAGES CERTIFICATE NUMBER: b/UU42fbf11f REVISION NUMBER:
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. Limits shown are as requested
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
A GENERAL LIABILITY GLO - EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY General Liablity DAMAGE T RENTED $1,000,000
SIR applies per policy terns & condl ions PREMISES Ea occurrence
CLAIMS-MADE ?X OCCUR MED EXP (Any one person) $10,000
PERSONAL & ADV INJURY $1,000,000 r
GENERAL AGGREGATE $5,000,000 r
N
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $2,000,000
X POLICY PE 0. LOC

A AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON-OWNED
AUTOS

UMBRELLA LAB OCCUR
EXCESS LIAB CLAIMS-MADE
EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR / PARTNER / EXECUTIVE ?
OFFICER/MEMBER EXCLUDED? N / A
(Mandatory in NH)
11j es. dese-ih_ ender --
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES
RE: Elk Creek Mine, Permit #1981-022
BAP 9265950-01
Business Automobile Cover
BODILY INJURY ( Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
EACH OCCURRENCE
AGGREGATE
WC STATU- OTI
TORY LIMITS ER
E.L. EACH ACCIDENT
E.L. DISEASE-EA EMPLOYEE
101, Additional Remarks Schedule, if more space is required)
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$1,000,000
O
Z
N
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N
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I I
CERTIFICATE HOLDER CANCELLATION _"
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE _
POLICY PROVISIONS.

Division of Reclamation AUTHORIZED REPRESENTATIVE
Mining and safety
1313
street
Room 215
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Denver
Denver Co 80203 USA G ? ?
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