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Western Surety Company
CHANGE NOTICE
WESTERN SURETY COMPANY is hereby requested to make the following additions to and -or deductions
from the Schedule of Employees attached to Bond No. 159425466 - , issued to
Weld County Human Resources _ Address Greeley, CO
subject to all the terms, limitations and conditions therein set forth.
This acceptance notice is issued with the distinct understanding that the liability of WESTERN SURETY
COMPANY shall under no circumstances be cumulative, and shall not exceed the amount of bond in effect as to any
employee or employees when the dishonest act of the employees shall have been committed, and shall in no event
exceed the maximum amount at any time specified tis to such employee or employees.
ADDITIONS
DATE OF
ADDITION
ITEM
NO.
NAMEPOSITION
LOCATION
AMOUNT
PREMIUM
CHARGE
01-13-09
102.
Barbara
Kirkmeyer
County
25,000.00
$
10.OOAP
01-13-09
103.
Sean P.
Conway
Commissioner
County
Commissioner
25,000.00
10.OOAP
DEDUCTIONS
DATE OF
DEDUCTION
ITEM
NO.
NAME
POSITION
LOCATION
AMOUNT
PREMIUM
CHARGE
01-13-09
01-13-09
5.
3.
Robert Madsen
William Jerke
Commissioner
Commissioner
25,000.00
25,000.00
'
NR
NR
Dated this 13th day of
NOTE - This form must be signed by
the Employer. If a Co -partnership, by
a member of the Finn: if a corporation,
by a duly authorized officer.
Form 216-11-2052 -'r
dnit eitte ct`7Ld/
January
2009
Weld County Human Resources
F.AlI'U)YEIO
By
WEST[
Br
PAI0.'I'. ISRI'I' I.AT SENIOR \;
:AII'I1 TI$I SSA;NATURE)
SURE% COMPANY
I? F'RES1I r. cm
2009-0292
P
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