2008-01-04_GENERAL DOCUMENTS - C1981008

• Permit No: C1981008
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 1/4/2008
• Doc Name: Certificate of Liability Insurance
• To: DRMS
• Permit Index Doc Type: Insurance
• Media Type: D
• Archive: No

ACORD
. CERTIFICATE OF LIABILITY INSURANCE CSR ~ DATE (MM/DD/YYYY)
.
WESTE-1 01/02/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Hays Companies HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
80 South 8th Street #700 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Minneapolis MN 55402
Phone : [phone] Fax :[phone] INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: Westchester Surplus Lines __ ___ ___ __ __
.
Western Fuels Association,Inc. .INSURER 8:- Illinois Union Insurance Co.
- - - - ~ -
°-- --- -
Attn : Nanc Kelly wsuRER c:
. - -- - ------ -- ---..~~_-'- --
_.. -
P. O. Box 3424
Denver. _CO 80233
T
INSURER D:
-.. _
~ - ..
-- __ .. ..__. _. - ..INSURER E:-
COVERAGES - '
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ~.
ANY REQUIREMENT, TERMOR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR I,
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'y I I DATEYMM DD/YY E I PDATE MMIDDIYYON I LIMITS
I_TR INSRD TYPE OF INSURANCE POLICY NUMBER
GEN ERAL LIABILITY EACH OCCURRENCE S 1 , 000 , 000
A }{ COMMERCIAL GENERAL LIABILITY G2203375A003 01/01/08 O1/O1/O9 PREMSES(OEaoccureDnce) 1 S 50, 000
_l CLAIMS MADE ~$ ~ OCCUR MED EXP (Any one person) S 10 , 00 0
PERSONAL 8 ADV INJURY S 1 , 000 , 0017
GENERAL AGGREGATE S 2, 000, 000
GEN 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG S 2 , 000 , 0 00
POLICY PRO-
JECT LOC
Em Ben.
1,000,000
AUT OMOBILE LIABILITY
~/
~
COMBINED SINGLE LIMIT

ANY AUTO `
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(Ea accident) S
ALL OWNED AUTOS ((~~
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(~
BODILY INJURY
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1
~ 1 (Per person) S
SCHEDULED AUTOS i a
.
HIRED AUTOS ~~ .~~;,\a ae'~ BODILY INJURY
p
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(Per accident) S
NON-OWNED AUTOS ~a
..~~
a
\~~
\5~ PROPERTY DAMAGE

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Per accident)
S
(
GA RAGE LIABILITY _ AUTO ONLY - EA ACCIDENT S
ANY AUTO ~ OTHER THAN _EA ACC I S_- __ -
AUTO ONLY: AGG S .
EXCESSIUMBRELLALIABILITY EACH OCCURRENCE S 20, 000, 000
$ }{ OCCUR nCLAIMSMADE X00 623889249 O1/O1/O8 O1/O1/O9 AGGREGATE- _
- S2O,000,000
-
_- -~ --~ -__- ~
-
- -- -_ -
DEDUCTIBLE S
~{ RETENTION $ 50 , 000 S
WORKERS COMPENSATION AND TORY LIMITS I E
R

EMPLOYERS' LIABILITY _
_
_
L. EACH ACCIDENT
E _ __ _ _ __ _ _

S
ANY PROPRIETOR/PARTNER/EXECUTIVE --
_
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE S

-, If y~s, describe undrer _
SP~CIAt-PR011S,.,P:S befmr.- ' i _ ~ _ .__ _ y -_ _
~ ~ E-i--B4SEASE - POL-ICY-I:IMI
~ -S
~ -
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Evidence of Insurance as respects
New Horizon Mine in Nucla, CO (Permit #C-81-008)
Includes use of Explosives
CERTIFICATE HOLDER CANCELLATION
Colorado Mined Land
Reclamation
Mined Land Division
1313 Sherman Street, RM 215
Denver CO 80203
COLOR-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
ACORD 25 (2001108) V HI.VKU I.VKrVKH11Vrv tyo8