2012-07-11_GENERAL DOCUMENTS - C1980003

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A ° CERTIFICATE OF LIABILITY INSURANCE DATE /YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 07/05 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 NAME: Marsh USA Inc. PHONE FAX 1166 Avenue of the Americas A/C No): E - MAIL New York, NY 10036 -2774 Attn. NewYork.certsC -Marsh com Fax 212- 948 -0500 CD ADDRESS: COMMERCIAL GENERAL LIABILITY `v V INSURERS AF COVERAGE NAIC # INSURER A: Hartford Fire Insurance Co 19682 008046 ALL cas - 11 - 12 �/� INSURED W R GRACE & CO. INSURER B NIA N/A INSURER C: Hartford Insurance Company Of Midwest 37478 7500 GRACE DRIVE �UL 1 ? ��? anon, INSURER D: Twin City Fire Insurance Co 29459 COLUMBIA, MD 21044 �dC1'd� c�aft3ty INSURER E: PERSONAL & ADV INJURY "'�M n and X S ELF - INSURED INSURER F: COVERAGES CERTIFICATE NUMBER: NYC:- 006102905 -29 REVISION NUMBER:4 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 SUER POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP /Y MM/DDYYY LIMITS GENERAL LIABILITY Self Insured 06130/2012 06130/2013 EACH OCCURRENCE $ 25,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 25,000,000 CLAIMS -MADE F—I OCCUR MED EXP (Anyone person) $ EXCLUDED PERSONAL & ADV INJURY $ 25,000,000 X S ELF - INSURED W R GRACE & CO GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ $ POLICY PRO LOC A AUT0M06i�c LIABILITY 10 CSE C47914 06, 06130/2013 COMBINED SINGLE LIMIT Ea accident 2,000,000 X BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ H CLAIMS-MADE AGGREGATE _ $ EXCESS LIAB DED I I RETENTION $ $ C WORKERS COMPENSATION 10 WN C47912 (ADS) 06/30/2012 06/30/2013 X WC STATU of H 1 TORY LIMITS I D AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED (Mandatory in NH) N/A 10 WEIR C47913 (WI) 0613012012 06/30/2013 E L EACH ACCIDENT $ 2,000,000 — E.L DISEASE - EA EMPLOYEE $ 2,000,000 If y es, describe under DESCRIPTION OF OPERATIONS below EL 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 CERTIFICATE HOLDER CANCELLATION Colorado Division of Minerals and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Geology THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn Jim Stark ACCORDANCE WITH THE POLICY PROVISIONS. 1313 Sherman Street - Room 215 Denver, CO 80203 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Dresa Allman ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD