2011-06-17_GENERAL DOCUMENTS - C1983059 ‎(3)‎

• Permit No: C1983059
• 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: JJD
• Email Name: SB1
• Media Type: D
• Archive: No

CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/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 LDER.
IMPORTANT: If the certificate holder is an D, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certai #i s may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER I 17 7V
tJ CONTACT
NAME:
Aon Risk services, Inc of Florida
afton, [phone]
[phone] jq
jaC. N
c
t71 jtaGlaM
222 Lakeview Avenue o. Ext):
/
. No.:
?1V151(311
suite 510 S3f('?„7
d E-MAIL
west Palm Beach FL 33401 USA mining isn ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED INSURER A: Zurich American Ins CO 16535
Oxbow Carbon & Minerals, LLC INSURER B: American Guarantee & Liability Ins Co 26247
1601 Forum Place
suite 1400 INSURER C:
West Palm Beach FL 33401-8101 USA
INSURER D:
INSURER E:
INSURER F:
UUVtKACitS GEKIIFIGAIE NUMBEK: b/UU4L1b(f9b 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
INSR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDIYYYY POLICY YYYY LIMITS
A GENERAL LIABILITY GLO 4 - EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY General Ll dbl lty DAMAGE 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
GEML AGGREGATE LIMIT APPLIES PER
POLICY F-] PRO- I I LOC
JECT I I
AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS
B NON-OWNED
AUTOS
B X UMBRELLA LIAH X OCCUR
EXCESS LIAR CLAIMS-MADE
DED X RETENTION 310,000
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR / PARTNER,
E%ECUTIVE
OFFICER/MEMBER EXCLUDED? ? N/A
(Mandatory in NH)
- - "_- ias,.describc ugdc•
DESCRIPTION OF OPERATIONS below I
BAP 921559SU-Ul
Business Automobile Cover
SIR applies per policy ter s & condi `m
06/0:
UMB926593701 It, 06/01/2011lions
Umbrella

m
G)
13
O
2
PERSONAL &ADV INJURY $1,000,000
GENERAL AGGREGATE $5,000,000
PRODUCTS - COMP/OP AGG $2,000,000
O
COMBINED SINGLE LIMIT
$1
000
000
Ea accident ,
,
BODILY INJURY ( Per person) O
Z
BODILY INJURY (Per accident) N
PROPERTY DAMAGE M
V
(Per accident)
O
EACH OCCURRENCE $25,000,000 U
AGGREGATE $25,000,000
E.L. EACH ACCIDENT
E.L. DISEASE-EA EMPLOYEE
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
RE: Terror Creek LLC , c-1983-059. Division of Reclamation, mining and safety is included as an Additional insured excluding
workers' Compensation and Employers' Liability as required by written contract but limited to the operations of the Insured
under said contract and always subject to the policy terms, conditions and exclusions.
CERTIFICATE HOLDER
Division of Reclamation, Mining
and Safety
1313 Sherman Street, Room 215
Denver CO 80203 USA
ACORD 25 (2010/05)
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.
AUTHORIZED( REPRESENTATIVE
e?Gron c%Z,rQ/c cJGl?urae4 ?Jna ??L'suu'?c
©1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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