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Y^ <br />,- <br />ACORN►® CERTIFICATE OF LIABILITY INSURANCE <br />DATE /2011 /YYYY) <br />os /zs/zo11 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />Marsh USA Inc. <br />1166 Avenue of the Americas <br />New York, NY 10036 -2774 <br />Attn: NewYork.certs @Marsh.com Fax: 212 - 948 -0500 !�� <br />CONTACT <br />NAME: <br />PHONE FA No): <br />E -MAIL <br />ADDRESS: <br />V <br />008046 - ALL cas - 11 - 12 ,, ` � <br />INSURERS AFFORDING COVERAGE <br />NAIC # <br />INSURER A: Hartford Fire Insurance Co <br />19682 <br />INSURED �;� ,� ♦ 6ti� a�Op' <br />W. R. GRACE & CO. <br />7500 GRACE DRIVE `` o L�u�� ae� <br />COLUMBIA, MD 21044 ,V�' d <br />-' <br />INSURERS: N/A <br />N/A <br />INSURER C : Hartford Insurance Company Of Midwest <br />37478 <br />INSURER D: Twin City Fire Insurance Co <br />29459 <br />INSURER E: <br />$ 5,000,000 <br />INSURER F: <br />$ EXCLUDED <br />COVERAGES \ CFRTIFICATF NIIMRFR- NYC-nnR1n9Qn5.9A RF \ /ICInfJ N1111AR9:0•d <br />THIS IS TO CERTIFY,THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAYBE) ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />SUBR <br />POLICY NUMBER <br />POLICY EFF <br />MM/DD/YYYY <br />POLICY EXP <br />MM/DD/YYYY <br />LIMITS <br />GENERAL LIABILITY <br />SELF INSURED <br />06/30/2011 <br />06/30/2012 <br />EACH OCCURRENCE <br />$ 5,000,000 <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE D OCCUR <br />DAMAGE ( RENTED <br />PREMISES Ea occurrence <br />$ 5,000,000 <br />MED EXP (Any one person) <br />$ EXCLUDED <br />PERSONAL & ADV INJURY <br />$ 5,000,000 <br />X SELF - INSURED <br />W. R. G & CO <br />GENERAL AGGREGATE <br />$ <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS - COMP /OP AGG <br />$ <br />POLICY PRO LOC <br />$ <br />A <br />AUTOMOBILE <br />LIABILITY <br />10 CSE C47908 <br />06/30/2011 <br />06/30/2012 <br />COMBINED SINGLE LIMIT <br />Ea accident <br />2,000,000 <br />X <br />ANY AUTO <br />BODILY INJURY (Per person) <br />$ <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />BODILY INJURY Per accident <br />( ) <br />$ <br />HIRED AUTOS NON -OWNED <br />AUTOS <br />PROPERTY DAMAGE <br />Per. ccident <br />$ <br />$ <br />UMBRELLA LIAB <br />H CLAIMS-MADE <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAB <br />DED RETENTION $ <br />$ <br />C <br />WORKERS COMPENSATION <br />10 WN C47906 (AOS) <br />06/30/2011 <br />06/30/2012 <br />X WC STATU- OTH- <br />D <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N <br />OFFICERrMEMBER EXCLUDED? � <br />(Mandatory in NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />N/A <br />10 WBR 047907 (WI) <br />06/30/2011 <br />06/30/2012 <br />TORY LIMITS I ER <br />— <br />E.L. EACH ACCIDENT <br />2,000,000 <br />$ <br />E.L. DISEASE - EA EMPLOYE <br />$ 2,000,000 <br />E.L. DISEASE - POLICY LIMIT I <br />2,000,000 <br />$ <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) <br />The coverage and limits stated above apply to Permit #C80 -003 <br />11.4 <br />Colorado Division of Minerals and <br />Geology <br />Attn: Jim Stark <br />1313 Sherman Street - Room 215 <br />Denver, CO 80203 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />of Marsh USA Inc. <br />Dresa Allman , ,� Q. � <br />© 1988 -2010 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD <br />