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ASt'uS ENDORSEMENT No. 4
Propel ry&Liabiliry For use with Fidelity Schedule Bonds (Position Form or Name Form) to add and/or deduct
onnm
Employees and to increase and/or decrease the amount of coverage on bonded Employees.
ATTACHED TO AND FORMING PART DATE ENDORSEMENT EXECUTED EFFECTIVE TIME OF ENDORSEMENT EFFECTIVE DATE Of ENDORSEMENT
OF BOND NO.
400 GJ 7043 10/11/84 12:01 AM 9/14/84
ISSUED TO
Weld County
It is agreed that the following amendments are made in the Schedule of the Bond:
NAME FORM ONLY POSITION FORM ONLY
POSITION OF ADDRESS NUMBER IN EACH TOTAL
POSITION AMOUNT OF
NAME OF EMPLOYEE EMPLOYEE WHERE EMPLOYED r
I AMOUNT OF COV. COVERAGE
I EACH POSITION
DEDUCTIONS FROM SCHEDULE: I
Lee Schmidt Deputy Dist. Attorney Greeley,Co 5,000.00
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ADDITIONS TO SCHEDULE:
Rebecca Jane Wilson Brunswig Deputy Dist. Greeley,Co 5,000.00
Attorney
Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, provisions,
agreements or limitations of the above mentioned Bond, other than as above stated.
Accepted: ST. PAUL FIRE AND MARINE INSURANCE COMPANY
L /f'" By ric
Attorney-in-Fact G Denora May y-in- 239
22240 Ed. 7-73 Printed in U.S.A.
INSURED
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