HomeMy WebLinkAbout000230.tiff Employers Mutual Companies
/ ECE1'. :._ 2 0 1990
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F•kill:. :1.N :;t.!RAN(: 1:: AOE:NC:Y
19.:34 EAS I I.81H AVENUE
DENVER, CO
80206
BOND NO: 13124563
-PI..k:A"TI:.: FURNISH A CURRENT SCHEDULE.: 0l" T-FIE:
PRINCIPAL : : r:MP1..OYEI S ON OW tNL1..OSE-D FORM SO lIIAT'
WELD COUNTY PUBLIC OF-F ICIA1..S : t F'NkWAI.. PREM:tUM MAY BF COMPUTE:D..
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TYPE: Of 130N[):. r
PUBLIC OFFIC;IAI...
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CJk:I...TOLE : - - THE: E:NCL.OSLD APPL.ICATIoN/INI:)IMNJ T Y
Wl~;I...1) C:f.IC1N iY AHRfEME:NT P4(.JSI BE COMPL.E lfD IN l:) :l'fl:l:t_
• AND SIGNED AS .INDICATED.
E3UNC) 1IERI' : 0:1/0.I•/91 10 01./0J./92
T'RANSAG'1':L ON
I:.:1 F-k.:C1 lVly: GATE 01/01 /91 :: ... - PL.E:AE;k.: FURNISH FINANCIAL... CTAT'E:NEN1 (S)
• A5 FOLLOWS:
1'YPf. OF TRANSACTION
_.._._......_..._..... ._.._....__.._._......._....................._.... AS OF:_.._._......._•._...._.._.
XRE:NkWA1.. PIS TURN • ....__.._..._........_....._.... .._....._....._..._•_..._.._.._...._. A;; CIF'.........._....._.._.._.....
:: _.__..__..._.._._.._.._._....__..._.._._.___._....,.._. A' OF'__.......___...._...._
AC)I):C1ICINAI... C:nN(::I:::I._I...Al :l:UN
PR;••.M7:CJM fl ANSAG I ION
PENAL. AMOUNT' r _._.._.._.._... .._._.._.._ ._.__.._..........•..__.._._.._..._...__.._._...__... _...._.............•..
$ 431.000 ...........•......._•......... ._....._._......_..._._..._......_.........._,._.._.._......._._.._....._......_.... ........ ...
F'RI:.:P13.1.'M:s 159/.00 6 _....._.._......_._.._.._._.•_.._._.M._.._.._•.._._._ ....._......_.._.._...._.................._..... .............._.........
.._..... ......_..... ..._._._.._..._...... ..__....._....._..___.__.........w.....__....._... _..............__..
KYSURCHARGE: _._.._..........._......_..._._.._......_._.._....._._ _._......_...._._._.._.._..._...._._._....•._....._....._._...._..
i:t h() t;(.1Rt 11r'IROL a$ ,� _...._._._._........_...._•....._.._..................•._.._..... _._._................._...... ... ..-.............._ ......_.
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DA'T'E: Of C.N1 RY: 11 / I6/,,o
F URN 7080 REV 5- 86 916 CS I Nt 6124563 9201
Employers Mutual Companies
LMPL R S M Ll .I F' A N T E S
HOME OF'F'I(::I OR L RANCI•I (31:[WW1 01'I ICI: PIC I1(:1I NI::' , IOWA
E_MPL(:LYE::RS MUTUAL_ CASUALTY COMPANY
CHANOI:: I_: N D O R S I M E: N 1
44?*4+:444*4:44:4=44:.******4,.0-;*:.- ***4.4 4- 4r***4..--k1)4.4 4e0 4 4c ***4-*, *•., 4 44:4}44..-4 0-.•
,(ATTACHED TO AND 1='ORM:I.NG * DA•I L: E:NDORSI MENT OR 41 *• E:F'F•L:C1•IVI: DA1 :: OF
*PART OF BOND/POLICY NO. * * RIDER EXECUTED 4 * ENDORSEMENT OR RIDER*
X * * *
S124168 * * :10/24/89 * * 09/29/89 *
1.1s eX'f.XX.W .(XXXW.AA .XXXXieXX :<•X:4:X:•XYXX9t*0(*.AY.A.;X•****X•}1 IPXXXXXX).XXXXXX8{XXXX4X4
OBL:[GEE: AGENT:
WELD COUNTY F R I TTS INSURANCE: AGENCY
1934 EAST 18TH AVENUE
915 10TH STREET
DENVER , CO
GREELEY , CO 80206
80631 AGENT• NO. AW-6055- 1
PRINCIPAL.:
WE:L.D COUNTY PUBLIC OFFICIALS
915 10 TH STREET
GREELEY , CO
NUE
IT IS HEREBY AGREED THAT THE WORDS:
SCHEDULE :
JACQUELINE: R. JOHNSON COUNT'Y COMMISSIONER $25,000.00
ARE HEREBY DELETED
AND THE: WORDS;
SCHEDULE:
CONSTANCE: L . HARBE:R1• COUNTY COMMISSIONER $25,000.00
ARE HEREBY SUBSTITUTED THEREFOR;
PROVIDED THAT, NO AMOUNT CARRIED UNDER THE BOND DURING ANY PERIOD SHAL.L.
HE CUMULATIVE WITH THE AMOUNT OR AMOUNTS CARRIED UNDER THE BOND UUR:[NG
ANY OTHER PERIOD OR PERIODS.
EMPLOYERS MUTUAL. CASUALTY COMPANY
KATH K E:RY
(AT RNEY--IN - AC )
/7/
/-
891359
DATE OF ENTRY: 10/24/89
7001 .1 REV. 4•-84 915 KT FNS S124168 9004
WELD COUNTY INPUT DOCUMENT
VENDOR NUMBER: L — ,--).-7,-- foe/ VOUCHER NUMBER: - - . '
L
i I
PAYEE: , 7 iii,c , CHECK
ADDRESS: 1 ci % // - I C t� I ' C.— Number Date Amount
/ / $
L EXPLANATION DETAILS OF DISBURSEMENT
Remittance Advice Orignal Encumbrance
Invoice 8 Inv. Date Due Date Discount Net Amount Expense Account Code P.O. Number TIP Account Code
/ /t ) r /2P A5-97/227 /a- AG' tJ-,-, -M7/, 3
I TOTAL: $ $/3.--9 , T
i
ATTACH COPY IF APPLICABLE 7/ /,
APPROVED BY: -r- ` t%'-,---4 =� z 21
(Department Htad)
_J
APPROVED BY:
J (Finance Department)
011152.010
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