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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,C0__
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
07-14-04 44 . Kimberly Duke Coroner $ 25, 000.00 $ 25.00AP
Investigator
DEDUCTIONS
DATE OF ITEM PREMIUM
DEDUCTION NO. NAME POSITION LOCATION AMOUNT CHARGE
07-14-04 40. Michaela Herder Coroner $ 25, 000.00 $ NRP
Investigator
Dated this- 14th day of __. July , 2004"tIN''' ntrono
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^e -. C''t County of Weld
- -..f`� S _. _-- (EMPLOYER)
W; = By --- MPLOYER'S SIGNATURE) - -
N This st be signed by
WEST N SURE COMPANY
the Bly a`¢!>I'sl'+ a.'to-partnership, by
a memb�iWi Elii?tirm; if a corporation, By
by a duly authorized officer. ( PAUL T.BRUFLAT,SENIOR E PRESIDENT
Form 216-11-2002 elyiAlyid4t/,tLiL<--
L- 2004-2280
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