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2012-12-31_GENERAL DOCUMENTS - C1981008
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2012-12-31_GENERAL DOCUMENTS - C1981008
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Last modified
8/24/2016 5:11:42 PM
Creation date
1/8/2013 7:56:38 AM
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Template:
DRMS Permit Index
Permit No
C1981008
IBM Index Class Name
GENERAL DOCUMENTS
Doc Date
12/31/2012
Doc Name
Certificate of Liability Insurance
To
DRMS
Permit Index Doc Type
Insurance
Email Name
MLT
SB1
Media Type
D
Archive
No
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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 <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE 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 SUBR POLICY EFF POLICY EXP W YYY <br />INSR, VD POLICY NUMBER (MM/DD/Y) (MM/DD/YYYY) <br />LIMITS <br />A <br />GENERAL <br />X <br />LIABILITY <br />COMMERCIAL GENERAL <br />LIABILITY <br />X <br />OCCUR <br />NAIC # <br />INSURED <br />Western Fuels Association, Inc. <br />12050 N. Pecos Street, Suite 100 <br />Westminster, CO 80234 <br />008844193 <br />01/01/13 <br />01/01/14 <br />EACH OCCURRENCE <br />$ 1,000,000 <br />DAMAGE TO RENTED <br />PREMISES (Ea occurrence) <br />$ 100, 000 <br />CLAIMS -MADE <br />MED EXP (Any one person) <br />$ <br />X <br />EEL $1,000,000 <br />PERSONAL B ADVINJURY <br />$ 1,000,000 <br />GE <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />'L AGGREGATE LIMIT APPLIES PER <br />POLICY FCT X LOC <br />PRODUCTS - COMP /OP AGG <br />$ 2,000,000 <br />Employee Benefits <br />$ 1,000,000 <br />B <br />AUTOMOBILE <br />X <br />X <br />X <br />LIABILITY <br />ANY AUTO <br />ALL OWNED AUTOS <br />SCHEDULED AUTOS <br />HIRED AUTOS <br />NON -OWNED AUTOS <br />CAB003292104 <br />01/01/13 <br />01/01/14 <br />COMBINED SINGLE LIMIT <br />(Ea accident) <br />$ 1,000,000 <br />BODILY INJURY (Per person) <br />$ <br />BODILY INJURY (Per accident) <br />$ <br />PROPERTY DAMAGE <br />(Per accident) <br />( <br />$ <br />$ <br />C <br />X <br />UMBRELLA LIAB <br />EXCESS LIAB <br />X <br />OCCUR <br />CLAIMS -MADE <br />BE 12816139 <br />01 /01 /13 <br />01/01/14 <br />EACH OCCURRENCE <br />$ 25, 000, 000 <br />AGGREGATE <br />$ 25, 000, 000 <br />X <br />DEDUCTIBLE <br />RETENTION $ 10,000 <br />$ <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY Y / N <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER /MEMBER EXCLUDED? I <br />(Mandatory in NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />N / A <br />WC STATU- OTH- <br />TORY LIMITS ER <br />E L EACH ACCIDENT <br />$ <br />E.L. DISEASE - EA EMPLOYEE <br />$ <br />E.L DISEASE - POLICY LIMIT <br />$ <br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) <br />Evidence of Insurance as respects New Horizon Mine in Nucla, CO (Permit #C -81 -008). Includes use of Explosives <br />RECEIVED <br />DEC 3 <br />Colorado Mined Land Reclamation Mined Land Division <br />1313 Sherman Street, RM 215 <br />Denver, CO 80203 <br />USA <br />I <br />v <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CHOW <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />ACOR CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MM/DD/YYYY) <br />12/28/2012 <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 1 - 612 - 333 - 3323 <br />Hays Companies <br />80 South 8th Street <br />Suite 700 <br />Minneapolis, MN 55402 <br />CONTACT <br />NAME: <br />PHONE <br />(A/C No ExU: 612 - 333 -3323 FAX <br />(A/C No). 612 - 373 -7270 <br />E - MAIL <br />ADDRESS: <br />PRODUCER <br />CUSTOMER ID #: <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURED <br />Western Fuels Association, Inc. <br />12050 N. Pecos Street, Suite 100 <br />Westminster, CO 80234 <br />INSURERA: LEXINGTON INS CO <br />19437 <br />INSURER B: ARCH INS CO <br />11150 <br />INSURERC: NATIONAL UNION FIRE INS CO OF PITTS <br />19445 <br />INSURER D : <br />INSURER E : <br />INSURER F - <br />COVERAGES <br />CERTIFICATE HOLDER <br />ericj <br />ACORD 25 (2009/09) <br />31036516 <br />CERTIFICATE NUMBER: 31036516 <br />REVISION NUMBER: <br />CANCELLATION <br />© 1988-2009 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />
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