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TATE OF COLORADO <br /> STATE FARM oy Romer, Governor <br /> ®® EPARTMENT OF NATURAL RES a(RCES <br /> I N SU RA N C E /{//S/ON OF WILDLIFE <br /> AN EQUAL OPPORTUNITY EMPLOYER <br /> John Y. Mumma, Director <br /> 6060 Broadway <br /> Denver, Colorado 80216 <br /> Telephone: (303) 297-1192 <br /> S ATEME OF INSURANCE CLAIMS <br /> The undersigned hereby warrants that as of the below date: <br /> 1. No claims have been placed against General Liability Insurance <br /> Policy #: <br /> Carried by (In urance Company) : <br /> or <br /> 46Claims have be 3h placed against <br /> General Liabil Ity Insurance policy #: <br /> Date: <br /> Type of Cover& +e <br /> Carried by (insurance Company) : <br /> 2. X No claims have been placed against Automobile Liability Insurance <br /> Policy #: S -11 Cj(_{ COS 006 ct►, S6(� 5 143 8o 5 o 6 k <br /> Carried by (insurance Company) : �}o F'I re J Cc(SLl ( 4y I MS c4j <br /> or <br /> Claims have been! placed against Automobile Liability Insurance <br /> Policy #: <br /> Date: <br /> Type of Coverage: <br /> Carried by (Inurance Company) : <br /> 3. There is no kno 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 Covera e: <br /> Carried by (In lurance company) : F <br /> YOuv"'ftft Pwm Agent <br /> In the approxi to amount of: $ �- A.6iaBITA <br /> For (type of c ;aim) 25 N. Harrison, P.O. Box 1120 <br /> `� iYRANCI Cortez, CO 81321 <br /> a. i � Gt i i r\l �f � - __ ® Phone;Ott. 565 3032 <br /> Contr cting Firm Insurance <br /> /Yf�YLI d.. l lam, <br /> By: u-r ,,UJCx-A4-tc CY . 0"7 <br /> Piasident, Owner or Partner -Authorized Representative <br /> Attest (SEAL) <br /> Phone: <br /> By: <br /> corporate secretary <br /> DATE: s._ DATE: <br /> *Claims have reduced aggregate by $ (Contractor must purchase <br /> additional insurance if claims reduce the annual aggregate below $500,000.00) . <br />