2011-07-06_GENERAL DOCUMENTS - C1980003

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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 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MM/DDIYYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY SELF INSURED • 06/30/2011 06/30/2012 EACH OCCURRENCE $ 5,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) 5,000,000 $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ EXCLUDED X SELF INSURED PERSONAL & ADV INJURY $ 5,000,000 W. R. GRACE & CO GENERAL AGGREGATE $ GEN'L AGGREGATE — 1 POLICY LIMIT APPLIES PRO - PER: PRODUCTS - COMP /OP AGG $ A - AUTOMOBILE LIABILITY —_ _ — 10 CSE C47908 __ — -- - 06/30/2011 -- _ - 06/30/2012 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,000 X ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED AUTOS NON -OWNED AUTOS BO DILY INJURY (Per person) -- BODILY INJURY (Per accident) ( ) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ UD WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below Y / N N N / A 10 WN C47906 (AOS) 10 WBR C47907 (WI) (W) 06/30/2011 0613012011 06/30/2012 06/30/201 X WC STATU TORY LIMITS OTH- FR E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOYEE $ 2,000,000 E.L. DISEASE - POLICY LIMIT 2,000,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The coverage and limits stated above apply to Permit #C80 -003 A CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh USA Inc. 1166 Avenue of the Americas New York, NY 10036 -2774 Attn: NewYork.certs @Marsh.com 008046- ALL- cas -11 -12 INSURED W. R. GRACE & CO. 7500 GRACE DRIVE COLUMBIA, MD 21044 Fax: 212 - 948 -0500 CONTACT NAME: PHONE (A/C. No. Ext): E -MAIL ADDRESS: FAX (A/C, No): INSURER(S) AFFORDING COVERAGE INSURER A : Hartford Fire Insurance Co INSURER B : N/A INSURER C : Hartford Insurance Company Of Midwest INSURER D : Twin City Fire Insurance Co INSURER E : INSURER F : DATE (MM/DD/YYYY) 06/29/2011 NAIC # 19682 N/A 37478 29459 :OVERAGES CERTIFICATE HOLDER CERTIFICATE NUMBER: NYC - 006102905 - 24 CANCELLATION • Colorado Division of Minerals and Geology Attn: Jim Stark 1313 Sherman Street - Room 215 Denver, CO 80203 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Dresa Allman i(Jivat. Q. ACORD 25 (2010/05) © 1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD