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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 — , issued to
county_of _._ _ _. 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 as to such employee or employees.
ADDITIONS
DATE OF ITEM PREMIUM
NAME POSITION LOCATION AMOUNT
ADDITION NO. CHARGE
01-30-06 68. Jason M. Bergevin Deputy District $ 5, 000.00 $ NAP
Attorney
DEDUCTIONS
DATE OF ITEM PREMIUM
NAME POSITION LOCATION AMOUNT
DEDUCTION NO. CHARGE
01-30-06 47. Theron Hoppe Deputy District $ 5,000.00 $ NRP
Attorney
01-30-06 67. Christopher Estoll Deputy District 5, 000.00 NRP
Attorney
Dated this,„ .3Oth day of January 2006_
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County of Weld
qt+ 400 v" ,, .;nom (EMPLOYER)
By
MPLOYER'S SIGNATURE)
WEST N SURE COMPANY
NaTE: This fonitcliAst be signed by
the Lm jojel tl '`,a`t o-partnership, by
a membAfrtfihL firm;if a corporation, By /
by a duly authorized officer. PAUL T.BRUFLAT,SENIOR V E PRESIDENT
Form 216. 1-2002
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