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anuuiowou iPZn cool <br />CERTIFICATE OF INSURANCE <br />issued by the <br />COLORADO COMPENSATION INSURANCE AUTHORITY <br />III IIIIIIIII IIII III <br />sss <br />720 South Colorado Blvd, Denver, Colorado 80222, (303) 782-4000 <br />AUG ~, % 1994 <br />MAIL TO: <br />DIV OF MINERALS 8 GEOLOGY <br />ATTN STEVE SHUEY <br />1313 SHERMAN ST X215 <br />DENVER CO 80203 <br />TO WHOM IT MAY CONCERN: <br />CERTIFICATE HOLDER: <br />DIV OF MINERALS & GEOLOGY <br />ATTN STEVE SHUEY <br />1313 SHERMAN ST #215 <br />DENVER CO 80203 <br />Dy ~~on c. r.,u~e,a, L. t:W,.~lc~y <br />This is to certify that this company has issued a Standard Workers' Compensation and Employers' <br />Liability Policy as described below cover's the liability imposed upon subject employers by the <br />Workers' Compensation Act of Colorado, said policy being in goocJ standing as of this date. <br />POLICY NUMBER: 001008-3 08/17/1994 <br />POLICY PERIOD: 01/01/1994 TO 01/01/1995 <br />INSURED: SOMERSET MINING CO. BROKER oFRECORD: c24no <br />ATTN: WALTER WRIGHT HOME LOAN AND INVESTMENT CO <br />P.O. BOX 535 145 NORTH 4TH STREET <br />SOMERSET CO 81434 GRAND JUNCTION CO 81501 <br />(303) 243-6600 <br />ORIGINAL EFFECTIVE DATE: 08/01/1989 <br />LIMITS OF LIABILITY <br />FOR EMPLOYERS' LIABILITY COVERAGE <br />Part Two of the policy, Limit of Employers' Liability, is amended to <br />include Bodily Injury by Accident $1,000,000 each accident <br />Bodily Injury by Disease $1,000,000 each employee <br />Bodily Injury by Disease $1,000,000 policy limit <br />IMPORTANT: THE COVERAGE DESCRIBED ABOVE IS IN EFFECT AS OF THE ISSUE DATE OF THIS CERTIFICATE <br />IT IS SUBJECT TO CHANGE AT ANY TIME IN THE FUTURE. <br />All policies are subject to_the following provision of the Workers' Compensation Act with-respect to <br />cancellation: <br />The issuance of this certificate of insurance is subject to section 8-44-110 C.R.S. which requires that a <br />thirty (30) day notice of cancellation be given unless cancellation is based on fraud, material <br />misrepresentation, nonpayment of premium or any other reason approved by the Commissioner of <br />Insurance; in such instances, CCIA will provide a ten day notice of cancellation. <br />Alteration of this document Is a criminal offense pursuant to Colorado Criminal Code 18-5-103: "A <br />person commits second degree forgery, if, with intent to defraud, he falsely makes, completes, alters, <br />or utters a written instrument which is or purports to be, or which is calculated to become or to <br />represent if completed: a commercial instrument. <br />Holders of this certificate may contact our Customer Service Department at 782-4000 to verify coverage <br />for the working classification listed on the back of this certificate. <br />("SEE BACK OF CERTIFICATE FOR CLASS COVERAGE AND OWNERSHIP COVERAGE DETAIL") <br />COLORADO COMPENSATION INSURANCE AUTHORITY <br />IIWIF fIYFLEI [A.U. fFP 1 UO1 il]ti011 <br />UPDATED ]/94 P26701 <br />