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TA TE OF COLORADO <br /> D <br /> oy Romer, Governor <br /> ai-016ra" EPARTMENT OF NATURAL RES URCES <br /> INSURANCE /V!S/ON OF WILDLIFE <br /> AN EQUAL OPPORTUNITY EMPLOYER <br /> John U. Mu==, Director <br /> 6060 Broadway <br /> Denver, Colorado 80216 <br /> Telephone: (303) 297-1192 <br /> S ATEMENT OF INSURANCE CLAIMS <br /> The undersigned hereby wa rants that as of the below date: <br /> 1. No claims have been placed against General Liability Insurance <br /> Policy #: <br /> Carried by (Insurance Company) : <br /> or <br /> -'4Claims have beten placed against <br /> General Liabi ity Insurance policy #: <br /> Date: <br /> Type of Coverage: <br /> Carried by (Insurance Company) : <br /> 2. X No claims have: been placed against Automobile Liability Insurance <br /> Policy #: s 71gy C-07 006 aK& S66 57a3 &S06H <br /> Carried by (I surance Company) : 6}A.jf- [-dPr,, Fl fe J CaStk a (+y ( nS tom, <br /> or <br /> Claims have been placed against Automobile Liability Insurance <br /> Policy #: <br /> Date: <br /> Type of Cover ge: <br /> Carried by (I urance Company) : <br /> 3. There is no wledge of facts which may lead to a claim. <br /> or <br /> There is knowledge of facts which may lead to a claim against <br /> Policy #: <br /> Type of Cover ge: <br /> Carried by (I4surance Company) : STA";ARM , yam,Sefts Pwm Agmt? <br /> In the approx mate amount of: $ �A.MORITA <br /> For (type of laim) 25 K Harm.P.O.B=1120 <br /> FRuuuNel� CWU.CO 81321 <br /> a.Y I ,,w o1 Pb Ott 565-3032 <br /> Contr cting Firm Insurance <br /> By: LtQilvt-c- 61, - 0-7 -// -97 <br /> P sident, Owner or Partner —Authorized Representative <br /> Attest (SEAL) <br /> Phone: <br /> By: <br /> corporate secretary <br /> DATE: S= DATE: " <br /> *Claims have reduced ag egate by $ (Contractor must purchase <br /> additional insurance if claims reduce the annual aggregate below $500,000.00) . <br />