2012-07-10_GENERAL DOCUMENTS - C1980003

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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 INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS NAIL # GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY INSURED W R GRACE & CO. 7500 GRACE DRIVE A 1 0707 anon, COLUMBIA, MD 21044 sdC vNl nt n g and c�aft3ty INSURER B N/A Self Insured 06/30/2012 06/30/2013 EACH OCCURRENCE $ 25,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) 25,000,000 $ INSURER F : CLAIMS -MADE OCCUR MED EXP (Any one person) $ EXCLUDED PERSONAL & ADV INJURY $ 25,000,000 X SELF - INSURED GENERAL AGGREGATE $ W R GRACE & CO PRODUCTS - COMP /OP AGG $ GEN'L AGGREGATE POLICY LIMIT APPLIES PRO- ,IFCT PER LOC $ A AUTOMObica X — LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED AUTOS NON -OWNED AUTOS 10 CSE C47914 06/30/2012 06/30/2013 COMBINED SINGLE LIMIT (Ea accident) 2,000,000 $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENT ON $ $ U C1 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED'? (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below Y / N N N / A 10 WN C47912 (AOS) 10 WBR C47913 (WI) 06/30/2012 06/30/2012 06/30/2013 06/30/2013 X WC STATU TORY LIMITS OTH ER E L EACH ACCIDENT $ 2,000,000 EL DISEASE - EA EMPLOYEE $ 2,000,000 E L DISEASE - POLICY LIMIT 2,000,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The coverage and limits stated above apply to Permit #C80 -003 Colorado Division of Minerals and Geology Attn Jim Stark 1313 Sherman Street - Room 215 Denver, CO 80203 I 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 of Marsh USA Inc. Dresa Allman L. ,eist Q, Q .,_..— A CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDD/YYYY) 07/05/2012 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 Marsh USA Inc. 1166 Avenue of the Americas New York, NY 10036 -2774 Attn. NewYork.certs@Marsh com Fax 212- 948 -0500 CD G`v V 008046 ALL -cas 11 -12 OG P►� CONTACT NAME: PHONE (A/C No. Extl: (A/C, No): E - MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL # INSURER A : Hartford Fire Insurance Co 19682 INSURED W R GRACE & CO. 7500 GRACE DRIVE A 1 0707 anon, COLUMBIA, MD 21044 sdC vNl nt n g and c�aft3ty INSURER B N/A N/A INSURER C : Hartford Insurance Company Of Midwest 37478 INSURER D , Twin City Fire Insurance Co 29459 INSURER E INSURER F : COVERAGES CERTIFICATE HOLDER ACORD 25 (2010/05) CERTIFICATE NUMBER: NYC 006102905 - 29 REVISION NUMBER: CANCELLATION © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD