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_AUIr lur,IlE hi j'rhl C7.':l :E.;I'YE L'Ar!Ilt'y tu.tCY III IIIIIIIIIIIIIIII ~~~J7- 's DAILY Rtf~7 ~~
<br />u7 I`. a, it :,l ~:, . ' _.
<br />n xE~ \ ` ~ dhe 17estern C _ sss _ Dmpany. ,
<br />V).,"~~1`t tJ^ 1 I FORT SCOTT, KANSAS ~~
<br />(9 A,CnCY POL ICI Rk L~7LR~ INUCx ~1.'lll I I`!p tU'AM. BUPCRU FUDIi IN',Y[LiIUN API`P'.~iD L~~
<br />m 1~a~
<br />L~ YR.
<br />1
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<br />Item 1
<br />CIf CCiIVE LAPIRAiIUN
<br />iCFIA laCg110N
<br />MD. DRY YR MD. DRY IR.
<br />Named Insured and Address
<br />:,J er3Cxa Furls,
<br />l.~t;l tar,
<br />i:OI(r l"r.a0 fiCi0
<br />Item 2. Policy Feriod:
<br />Elam Sr.*xtn-:tin 1 1q~3 to rK bat Ci'tT~Ci 11 1934
<br />1201 A. M, sleadard tlrle al tFie acaress of the name msuretl as sta ~d herein.
<br />The nalned insured Is: ^ Individual(s); ^ Parl„ership; 31' Corporal ion; ^ loin! Venture; (Other)
<br />The business of the named insured is
<br />COY. OR CLASS PRCMIUM
<br />ORr CINRL I ACTUAL
<br />-.-
<br />go PU'{nEa ~,,
<br />(J T
<br />it --J
<br />/ ~
<br />full Service
<br />Insurance
<br />_ 508 MAIN ?' ~E _
<br />WAISENBU.nG, CO ~' a-
<br />!a ~ 738-1940 ~,.';`y-~.,
<br />y,~ - _
<br />0031 :~tLl~ ".lri1n~'S
<br />Item 3. The insurance aHarded is only With respect to such of the lollowing coverages as are indicated by specific Ilmits of liability. ilia Ilmit of The V.„fern's
<br />liability shall be as stated herein, subject to all the !elms of this policy having reference thereto.
<br />Part
<br />limits of L
<br />Part I. Ccmplehensi:e Genaral Liability
<br />p. Bodily Injury Liability
<br />B. Property Bamage Liability
<br />Part II. Comprehensse Autumobi L=Liability ~C~BOdily Injury Liability
<br />~ D. Property Damage Liability
<br />Exclusion "r" of Fart I of this policy is deleted if the Completed Operatierrs
<br />Hazard below is designated O~
<br />Exclusion "s" of Part I of this pLlicy is deleted if the Products Hazard below
<br />is designated ^x.
<br />^ Completed Operations ^ Products Hazard
<br />Exclusion "e" of Part I of this policy does not apply to watercraft less than
<br />9eC zanAthousand dollars each oc:. -.nee
<br />_ b559 thousand dollars agglega'=
<br />ECC eiuatJOUSand dollars each oc ~e~Le
<br />_ f,SS~ thousand dollars aggregzte
<br />SCe ezic!Ulousand dollars each De~::n
<br />G5S9 thousand dollars each or. ace
<br />__ __~!;e~ spat ousand dollars each o(~ e~ue
<br />~~
<br />Exclusion (ql (ll of Part I of this policy is deleted if the Explaslon Haut `.Now
<br />is designated O~
<br />Exclusion (qI 121 of Part I of this policy is deleted if the Collapse Haza:' Show
<br />is designated O~
<br />Exclusion Iq) 13) is deleted if the Underground Property Uamage Ha:erd Is
<br />designated O.
<br />twenty six feet in overall length, if watercraft below is designated ^. g;Explosion Hazard ^ Collapse Hazard
<br />^ IYalercratt ^ Underground Property Damage Hazard _ J
<br />If indicated herein, ialerim adlusfinents of premium shall be made: ^Semf-Annually ^ Quarterly ^ Monthly Deposit Premium $ 1 ~, ~1 ~.: ` s•-•^ :.-..t
<br />When policy' period is in excess of one year, the deposit premiums are payable as follows:
<br />General Liability Automobile
<br />In Advance $ $
<br />1st Anniversary $ to he determined
<br />2nd Anniversary E to he determined
<br />Item 4. The declarations are completed on attached schedules and endprsements designated
<br />GL^.OI9,^.L~^2G, 5559, G53~-F 1, E&?1-R2, GFS`.Sr3-F.6, 1_01!i. 57K), 1177.-i'S. i1S.S-ItG, 15!;5,
<br />15~f= 1, 1675, frill-TLS. Lz'i 1r5, G'li 2I0, T.,!2052h, I^1/~b,
<br />Item 5. The premium for this policy is modified by reason of the insured's having in effect at inception dale of this policy the following insurance:
<br />Name of Company PDlicy No. Coverage Provided Limits of Liability ~`piring
<br />Item 6. Unless other wise staled herein, the named insured has disclosed to The Vlestern all haz s d hereund n to exist at the eHec6ve ds . of this
<br />policy. / i i P,4 .1~
<br />'',.lrr:::::ErC, .'olnrado -•e.,~r l;c"c°. ~1_y-/__a
<br />1:'-i^-.c. '~-t Countersigned at
<br />A.uthD;¢ed Agent
<br />LILAC I CUV. I ClA$S I CXPUSURE
<br />(NO.. Sleet, Town, Lounly, Slate, Zip Code)
<br />Inc. NOV 10 1983
<br />MINED LAND RECLAMATION DIVISION
<br />Celo. Dept. 01 Natural Resources
<br />:narA Ar apn RA _AUDIT COPY
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