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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 Weld _. . _.. _. -.. . - 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
PREMIUM
DATE OF ITEM NAME POSITION LOCATION AMOUNT CHARGE
ADDITION NO.
01-11-05 49. Kenneth R. Buck Di $ $
strict Attorney
25, 000.00 87 .SOAP
DEDUCTIONS
PREMIUM
DATE OF ITEM NAME POSITION LOCATION AMOUNT CHARGE
DEDUCTION NO. _t
$ $
•
30th December , . 2004 .
Dated this _—___-_-day of __ __ _- --
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Ip.£T} County of Weld
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43`..7 --.(EMPLOYER)
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_ MPLOYER'S SIGNATURE)
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as t r'fAse WEST ' N SURE COMPANY
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NOTRi This fori>, >jitist be signed by
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the �iM��'�Qf?a'1'{'ato-partnership, by
b�a memYbofthetirn1;if a corporation, By - -
PAUL T.BRUFLAT,SENIOR V.'E PRESIDENT
by a duly authorized officer.
F rm 216-11-2002
Ce?14/24 2005-0369
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