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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. 158425466
Weld County Human Resources
Address Greeley, CO
subject to all the terms, limitations and conditions therein set forth.
issued to
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 tune specified as to such employee or employees.
ADDITIONS
DA'Z'E (11
.ADDITION
ITEM
NO.
NAME
POSITION
LOCATION
AMOUNT
PREM0IM
atARCE
02-17-09
104.
Audra
K.
Ray
Deputy District
Attorney
'7
5,000.00
' NA
DEDUCTIONS
DATE OF
DEDUCTION
ITEM
NO
NAME
I'OSI'I'ION
IOt':1TION
:1M0I'NT
PREMIlnt
CHARGE
02-17-09
82.
Anita Jain
Deputy District
5,000.00
5
NR
Attorney
02-17-09
89.
Melissa Fox
Deputy District
5,000.00
15.25R5
Attorney
02-17-09
90.
Chad Zito
Deputy District
5,000.00
15.24RP
Attorney
Dated his 17th day of
NOTE - This form must be signed by
the Employer. If a Co -partnership, by
a member of the Firm: if a corporation.
by a duly authorized officer_
Form 216-11-2002
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CVn,�)12c.21 delCP-tX-9Zs7i
,1-?/;t5:/;?0(9
February
2009
I3v
Weld County Human Resources
11'1'11 I?R'S SIGNATGTF)
WESTE N SURETA COMPANY
I'AI- 1.' I' 1311 'FLAT. SENIOR 1
I'IiESII)EN I'
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