HomeMy WebLinkAbout20121376.tiff WELD COUNTY BOARD OF DIRECTOR
CONMISSIOP,IERS OATH OF OFFICE
I012 MAY 23 A II: 40 32-1-901, C.R.S., and
Colorado Constitution Article 12, §9
RECEIVED STATE OF COLORADO
LARIMER AND WELD COUNTIES
NORTH WELD COUNTY WATER DISTRICT
I, Robert Arnbrecht, will faithfully support the Constitution of the United States and of the State of Colorado, and
the laws made pursuant thereto, and will faithfully perform the duties of the office of Director of North Weld County Water
District, upon which I am about to enter. _ 1
signature o oat to<er
Subscribed and sworn to before me this lX day of /key ,
By. £Z
LI, on ut ra(
hi6'zed to administer oaths,
Chairman of the Board of Directors)
IF SWORN OR AFFIRMED BEFORE A NOTARY THE FOLLOWING SHOULD BE COMPLETED.
STATE OF COLORADO
ss.
COUNTY OF
Subscribed and sworn to before me this day of , 20
(notary commission expiration) (notary signature)
SEAL
3130 '1 a-- ` 2012-1376
Uti
Division of Local Government—Department of Local Affairs / .30-I a- B-73
Revised 519/12
BOARD OF DIRECTOR
OATH OF OFFICE
32-1-901,C.R.S.,and
Colorado Constitution Article 12, §9
STATE OF COLORADO
LARIMER AND WELD COUNTIES
NORTH WELD COUNTY WATER DISTRICT
I, Todd Bean, will faithfully support the Constitution of the United States and of the State of Colorado, and the
laws made pursuant thereto, and will faithfully perform the duties of the of iic ector of North Weld County Water
District, upon which I am about to enter.
signature o oat taker)
Subscribed and swom to before me this 1V day of ifigy , 20/'j .
By:�fle',
ers atborized to administer oaths,
Chairman of the Board of Directors)
IF SWORN OR AFFIRMED BEFORE A NOTARY THE FOLLOWING SHOULD BE COMPLETED.
STATE OF COLORADO
)ss.
COUNTY OF
Subscribed and sworn to before me this day of , 20
(notary commission expiration) (notary signature)
SEAL
Division of Local Government—Department of Local Affairs 8-73
Revised 59/12
BOARD OF DIRECTOR
OATH OF OFFICE
32-1-901, C.R.S.,and
Colorado Constitution Article 12, §9
STATE OF COLORADO
LARIMER AND WELD COUNTIES
NORTH WELD COUNTY WATER DISTRICT
I, Gary Simpson, will faithfully support the Constitution of the United States and of the State of Colorado, and the
laws made pursuant thereto, and will faithfully perform the duties of the office of Director of North Weld County Water
District, upon which I am about to enter.
426 Jr 4A-,
(signature of oath taker)
Subscribed and sworn to before me this /y day of 4rY , 20/ Z.
By: a „gg��
(Per �h autt4rr : o administer oaths,
Chairman of the Board of Directors)
IF SWORN OR AFFIRMED BEFORE A NOTARY THE FOLLOWING SHOULD BE COMPLETED.
STATE OF COLORADO
) ss.
COUNTY OF
Subscribed and sworn to before me this day of , 20
(notary commission expiration) (notary signature)
SEAL
Division of Local Government—Department of Local Affairs 8-73
Revised 5/9/12
Colorado Special Districts Property and Liability Pool
ComprelsaminOboe Certificate Heider Declarations
Master Coverage Policy Number: CCP0097259
Certificate Number. nr 7-618 Coverage Period: 1/1/2012 Until Cancelled
Named Sarrnbe: Billing Period: 1/112012 to 1/111018
North Weld County War District
PO Box 56 Staley Manna Corporation
Lure.CO 006460056 2084 S.MAstendtea Street
Denver,CO 80210
Covered ERISA Plan.
Cov.raae.Limits of Insurance and Deductibles; tintb:
Pubic Employee Dishonesty Coverage: $15,000
-Limit is Per Loss
-Faithful Pertormence of Duty
-Officers,Directors and Trustees
•Includes Welfare end Pension Plan ERISA Compliance
it Covered Plan is shown on application
-Includes Volunteer Workers as Employees
Forgery or Alteration Coverage: $15,000
Theft,Disappearance and Destruction Coverage:
Printery$5,000 deductible provided by Money and Securities
Section of the Pool's Property Coverage Document
otherwise Crime deductible below will apply
Inside Premises Deductible $5,000.00 $15,000
Outside Premises Deductible $5000.00 $15,000
Computer Fraud and Funds Transfer Fraud Coverage:
Units we equal to Employee Dishonesty Coverage.or$25.000 or.whichever Is isms
Money Orders and Counterfeit Paper Currency Coverage: $15,000
Crime Deductible: $250.00
Contribution: $902.11
Polley Forms: CR 00200506 Govanrenea Caine Pay
CR 25070300 kettle Bas W ed C6eaas a busbies an Cam ilia.a Employees
CR 26000000 Includes Spedeed NonCaapansalad OMs.as Employes
CR 26090300 kends Vckaaeer Waders as Employees
CR 25190606 Fankk/Psrtrmars al Duly
CR 2512030D Includes Treasures or Tax Colsaa_as Enpryas
CR 02151104 Colorado Changes
UCR-129.70 Named tamed
This Certificate Holder Declaration is made and is mutually accepted by the Pool and the Named Ibrahim
subject to an terms which are made a part of the Master Camprehenmlve Crime Polley. This Certificate
represents any a thief summary of coverages. Please refer to the Master Policy Document for actual coverage,
terms,conditions,and exclusionss.L/1J/n/
Countersigned by.. P4.ivi 74. Monday.November 21,2011
iz Authorized Representative
Entity IDIk 54082
/,'?
404.
Colorado Special Districts Property and Liability Pool
Public Entity Liability Certificate Holder Declarations
Master Coverage Document Number. PEL 01 01 12
Certificate Number 25054082.518 Coverage Pedork 11112012 to 11112013
IS Bmkeraf sees
North Web Canty Water District Steffy Insurance C otpmratlon
PO Box 58 2084 S.kdlwaulue Street
Lucerne.CO 808480058 Denver.CO 80210
Coverage is provided for only those averages indicated below for which a contribution Is shown.
Per Ocummnce Annual Aggregate
Coverage Limp Umit Dednca isle Contribution
Public Entity Liability Coverage $1.000.000 None $500 57.200.11
Including: IncludedOe General Liability Incl dsd Nona 5500
Medical Payments-Premises 510.000 510.000 WA Included
Employee Benefits Admin.Wblly Included None $500 included
Public Officials Liability Included None S5.000 53.85119
Employment Practices Liability Included None •$10.000 Included
Pre Loss Legal Assistance 52.000 $4.000 None Included
No-Fault Water IL Sewer Backup 510.000 $30.000 5500 Included
CyberLi SW 5200.000 ••51.000.000 None Included
Piduciary Liability 3200.000 "$1.Oo0.0o0 None included
Excess Liability $4.000,000 None WA $4.170.25
Aub Liability Included !tone $500 $8.355.39
Medical Payments-Auto 8.000 $10.000 None Included
Non Ownedniked Auto Liability included None None $132.00
Uninsured Moloriet $1.000.000 None None Included
Auto Physical Damage Per Schedule Per Schedule Per Schedule $10.934.07
Hired Auto Physical Darner $50.000 WA $5004500 $65.00
Auto Physical Damage-Employee $2,500 WA WA banded Deducele Reimbursement _
TOW Contribution: 332.509.22
•Employment Practlees Liability Deductible:50%Of loss,subject to a madmum deductible of$10.000 each
occurrence
••Cyber Liability and Fidudery uably each have a$1.000.000 Al MemberAmual Aggregate Limt
fdkitfo al endorsements that mar be somata b Member.
This Certificate Holder Declaration I.made and is mutually aeaeptid by the Pool and the Named Member
subject to all tinny which are made a part of the Public Entity Liability Coverage Document This
Certificate represents a brief summery of averages.Please refer to the ulster Coverage Document for
actual average.bons,conditions.and exclusions.
.. . -Countersigned W k 4�dt',r Monday.Ncvember21.2011
Authorized der
Entity War 54082
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