2019-02-13_REVISION - M2000077 (5)

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EVANSTON INSURANCE COMPANY ' State Transaction Code: MARKEL° COMMON POLICY DECLARATIONS POLICY NUMBER: 3AA176888 RENEWAL OF POLICY:3EG1933 Named Insured and Mailing Address(No.,Street,Town or City,County,State,Zip Code) PK Enterprises Inc NO FLAT PO BOX 729 Divide,CO80814 CANCELLATIONS Policy Period:From 06/10/2018 to 06/10/2019 at 12:01 A.M.Standard Time at your mailing address shown above. BUSINESS DESCRIPTION: GRAVEL PIT EXCAVATION FORM OF BUSINESS ❑ Individual ❑ Partnership ❑ Joint Venture ❑ Trust ® Corporation ❑ Limited Liability Company ❑ Other Organization: Audit Period:Annual unless otherwise stated: FTZ Code: IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY,WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PART(S),BUT ONLY FOR WHICH A PREMIUM IS INDICATED.THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. Commercial Property Coverage Part $ Not Covered Commercial General Liability Coverage Part $ 1,500.00 Commercial Inland Marine Coverage Part $ Not Covered Commercial Ocean Marine Coverage Part $ Not Covered Commercial Professional Liability Coverage Part $ Not Covered Commercial Automobile Liability Coverage Part $ Not Covered Liquor Liability Coverage Part $ Not Covered Crime Coverage Part $ Not Covered Other Coverages: Terrorism-Certified Acts $ Excluded $ Premium Total $ 1,500.00 Other Charges: Taxes and Fees-See MDIL 1002 $ 148.00 GRAND TOTAL $ 1 648.00 THIS CONTRACT IS DELIVERED AS A SURPLUS LINE COVERAGE UNDER THE"NONADMITTED INSURANCE ACT'. THE INSURER ISSUING THIS CONTRACT IS NOT LICENSED IN COLORADO BUT IS AN APPROVED ELIGIBLE NON-ADMITTED INSURER. THERE IS NO PROTECTION UNDER THE PROVISIONS OF THE "COLORADO INSURANCE GUARANTY ASSOCIATION ACT". Producer Number,Name and Mailing Address 212335 State Surplus Lines License# MDIL 1000 0811 Page 1 of 2