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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
04-12-04 41. Ann Marie M. Spain Deputy Dist. Atty. $ 5, 000.00 $ 13.50AP
04-12-04 42. David M. Goddard Daputy Dist. Atty. 5, 000.00 13.50AP
DEDUCTIONS
DATE ITEM NAME POSITION LOCATION AMOUNT
DEDUCTION NO. PREMIUM
CHARGE
$ $
Dated this 12th day of ___.._April, 2004_
-' r� County of Weld
Wit,,. QQ®�T,��' T (EMPLOYER)
in ' 1(1':gs By .
y MPLOYER'S SIGNATURE)
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* '
Nd ,,"Lhis fo ust be signed by WEST N SURET COMPANY
the '¢''`trop o-partnership, by C.--/a memo&softhnirm;if a corporation, By PAUL T.BRUFLAT,SENIOR V 'E PRESIDENT
by a duly authorized officer.
Form 218-11-2002
2004-1726
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