2012-07-11_GENERAL DOCUMENTS - C1980003

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Y^ ,- ACORN►® CERTIFICATE OF LIABILITY INSURANCE DATE /2011 /YYYY) os /zs/zo11 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 !�� CONTACT NAME: PHONE FA No): E -MAIL ADDRESS: V 008046 - ALL cas - 11 - 12 ,, ` � INSURERS AFFORDING COVERAGE NAIC # INSURER A: Hartford Fire Insurance Co 19682 INSURED �;� ,� ♦ 6ti� a�Op' W. R. GRACE & CO. 7500 GRACE DRIVE `` o L�u�� ae� COLUMBIA, MD 21044 ,V�' d -' INSURERS: N/A N/A INSURER C : Hartford Insurance Company Of Midwest 37478 INSURER D: Twin City Fire Insurance Co 29459 INSURER E: $ 5,000,000 INSURER F: $ EXCLUDED COVERAGES \ CFRTIFICATF NIIMRFR- NYC-nnR1n9Qn5.9A RF \ /ICInfJ N1111AR9:0•d 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 MAYBE) 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 SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY SELF INSURED 06/30/2011 06/30/2012 EACH OCCURRENCE $ 5,000,000 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR DAMAGE ( RENTED PREMISES Ea occurrence $ 5,000,000 MED EXP (Any one person) $ EXCLUDED PERSONAL & ADV INJURY $ 5,000,000 X SELF - INSURED W. R. G & CO GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY PRO LOC $ A AUTOMOBILE LIABILITY 10 CSE C47908 06/30/2011 06/30/2012 COMBINED SINGLE LIMIT Ea accident 2,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident ( ) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per. ccident $ $ UMBRELLA LIAB H CLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED RETENTION $ $ C WORKERS COMPENSATION 10 WN C47906 (AOS) 06/30/2011 06/30/2012 X WC STATU- OTH- D AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICERrMEMBER EXCLUDED? � (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A 10 WBR 047907 (WI) 06/30/2011 06/30/2012 TORY LIMITS I ER — E.L. EACH ACCIDENT 2,000,000 $ E.L. DISEASE - EA EMPLOYE $ 2,000,000 E.L. DISEASE - POLICY LIMIT I 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 11.4 Colorado Division of Minerals and Geology Attn: Jim Stark 1313 Sherman Street - Room 215 Denver, CO 80203 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 , ,� Q. � © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD