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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. 615842546 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 NAME POSITION LOCATION AMOUNT PREMIUM
ADDITION NO. CHARGE
01-07-04 38 . Christopher Robillard Coroners $ $
Investigator 25, 000.00 NAP
01-07-04 39. Dean Beers Coroners
Investigatoe 25, 000.00 NAP
01-07-04 40. Michaela Herder Coroners
Investigator 25, 000.00 NAP
DEDUCTIONS
DATE OF ITEM NAME POSITION LOCATION AMOUNT PREMIUM
DEDUCTION NO. CHARGE
01-07-04 13. Christopher Collins Deputy District $ $
Attorney 5, 000. 00 NRP
Dated this 7th day of. _ - January___ _ 2004
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County of Weld
d4r'; Qd"cc A % (EMPLOYER)
By
*�" MPLOYER'S SIGNATURE)
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N&TR=-This forltist be signed by WEST N SURE COMPANY
the 1fiii$aftiJr* o.partnership, by
a membF4if4tti irm;if a corporation, By
by a duly authorized officer. PAUL T.BRUFLAT,SENIOR E PRESIDENT
Form 216- 2002
-7 2004-0302
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