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iStRiVl ENDORSEMENT No. 5
ProIR'rly&Liabpli For use with Fidelity Schedule Bonds (Position Form or Name Form to add and/or deduct
huunnce ) /
Employees and to increase and/or decrease the amount of coverage on bonded Employees.
(P0)
ATTACHED TO AND FORMING PART DATE ENDORSEMENT EXECUTED EFFECTIVE TIME OF ENDORSEMENT EFFECTIVE DATE OF ENDORSEMENT
OF BOND NO.
400 GJ 7043 1/2/85 12:01 AM 1/2/85
ISSUED TO
VE: C
Weld County D r,I A�+
It is agreed that the following amendments are made in the Schedule of the Bond: JHN 1 4 1985
NAME FORM ONLY POSI]II FORM ONLY _ i
POSITION OF ADDRESS NUMBER liNcr L _ TOTAL
POSITION
NAME OF EMPLOYEE EMPLOYEE WHERE EMPLOYED r AMOUNT OF
I AMOUNT OF Coy. COVERAGE
EACH POSITION
DEDUCTIONS FROM SCHEDULE:
$
Norman Carlson County Commissioner Greeley,CO 25,000.00
Chuck Carlson County Commissioner Greeley, CO 25000.00
,
John Martin County Commissioner Greeley, CO 25,000.00
ADDITIONS TO SCHEDULE:
$ $
C. W. Kirby County Commissioner Greeley, CO 25,000.00
Gordon E. Lacy County Commissioner Greeley, CO 25,000.00
Frank Yamaguchi County Commissioner Greeley, CO 25,000.00
I
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 M RINE INSURANCE COMPANY
,— J
By KathyLee,ti Attorney-in 240
22240 Ed. 7-73 Printed in U.S.A. t/
INSURED
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