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RESOLUTION
RE: APPROVE PURCHASE OF SURETY BOND FOR WORKERS COMPENSATION
INSURANCE PROGRAM
WHEREAS, the Board of County Commissioners of Weld County,
Colorado, pursuant to Colorado statute and the Weld County Home
Rule Charter, is vested with the authority of administering the
affairs of Weld County, Colorado, and
WHEREAS, the County has reviewed the alternatives to the
Workers Compensation Insurance Program and has determined that the
best alternative is to keep the County's current Workers
Compensation Insurance Program with a self-insurance program that
provides improved administrative services as well as reduced costs
to the County, and
WHEREAS, the Industrial Commission of Colorado requires that
all self-insured organizations post a surety bond with the
Commission to guarantee the payment of Workers Compensation claims
incurred by the County, and
WHEREAS, the County desires that the surety bond be purchased
from The Aetna Casualty and Surety Company, an insurance company
authorized to do business in the State of Colorado, a copy of said
bond being attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County
Commissioners of Weld County, Colorado, that the Chairman be, and
hereby is, authorized to enter into an agreement with The Aetna
Casualty and Surety Company to purchase a surety bond for the
County's self-insured Workers Compensation Insurance Program.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and
hereby is, authorized to sign said agreement.
PE 0003
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871043
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RE: PURCHASE OF SURETY BOND
The above and foregoing Resolution was, on motion duly made
and seconded, adopted by the following vote on the 5th day of
August, A.D. , 1987, nunc pro tunc April 25 , 1987.
Q aewn hA _ _/-_ ' BOARD OF OUNTY COMMISSIONERS
ATTEST: 0 �^^�'^ u°�a^u'�v WELD CO T LORADO
Weld County Clerk and Recorder
and Clerk to the Board Go , Chairman
('
t t G2yc�,k, o 1 , c.�r d ) C. . irby, Pro f em
D puty County C k
EXCUSED
APPROVED AS TO FORM: Gene R. Brantnneer
c ---v7 < ,doce_if c i 4\64:10tN,
hnso
County Attorney
Frank Yamaguchi
871043
APPLICATION FORJCENSE, PERMIT, THE !ETNA C-=-5UALTY AND SURETY COMPANY
MISCELLANEOUS ST INSTRUMENT,
H� ord, Connecticut 06115
_.`..H:CASVALI ' INTERNAL REVENUE, CUSTOMS,
'r
COURT AND WAREHOUSE BONDS
Bond Number 19 S 100130670 BCA Field Office Denver, Colorado Producer A. J. Gallagher
QUESTIONS 1-8 MUST BE COMPLETED FOR ALL BONDS AND APPLICATIONS SIGNED{3270}
1. Applicant's name in full Weld County,_ Colorado
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(Print or Type) (If a firm, give names of partners)
2. Occupation Business Address 915-10th Street, Grpal py,, Colorado 80631
(Give Number,Street,City,State and Zip Code)
3. Residence address
(Give Number,Street,City,State and Zip Code)
4. Amount of bond $ 300,000.00 Date of bond 4-25-
, 19 87 Expires 19_
5. To whom is bond given (Obligee) State o£ Colorado
(Give exact and complete name,especially if corporation)
6. Address of above
(Give Number,Street, City,State and Zip Code)
7. Nature or character of bond required Worker's Compensation Bond
8. Has application for this bond been made to another company? If so,state particulars
COMPLETE ADDITIONAL QUESTIONS RELATING TO TYPE OF BOND REQUIRED
LICENSE, PERMIT, MISCELLANEOUS
1. FINANCIAL STATEMENT REQUIRED
LOST INSTRUMENT BOND
1. Description of Lost Instrument
(Is it an Investment Bond?Stock Certificate?Note? Life Insurance Policy?,etc.)
2. Serial No.of Lost Instrument Date of issue of Lost Instrument Negotiable?
If a bond or note,give maturity date
If a stock certificate, number of shares Par value ea. sh.$ Present market value ea. sh.$
If a policy, give name of beneficiary
3. If duplicate to be issued,state—
a) In whose name will the duplicate be issued?
b) In whose name does ownership of the lost security appear on the records of the issuing corporation or its Registrar?
c) If not stock, state amount for which duplicate is to be issued $
4. If payment to be made on the lost instrument, state amount to be paid $ _
5. Has the person in whose name the securities stand ever executed any assignment or Power of Attorney whatsoever that would enable
any other person to transfer said lost instrument(s)?
(If so, attach explanatory letter if necessary)
6. Has the lost instrument(s) in any way been transferred, endorsed (either in blank or otherwise), hypothecated or pledged as security
for a loan or as margin or for any other purpose?
(If so,attach explanatory letter if necessary)
7. State date when the lost instrument was last seen,and state where seen and by whom
8. FINANCIAL STATEMENT REQUIRED
CAT.289434
2286) ED.4-78 871073
r �J PRINTED IN V.S.A.
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INTERNAL REVENUE AND CUSTOMS BONDS
1. Nature or character of bond(s) required (give bond form number)
2. What commodity is being entered?
3. Character of business conducted
4. In what Internal Revenue District are you located?
5. How long have you engaged in this business?
6. Have you ever had any trouble with the Internal Revenue Department? or Customs Department?
7. Do you own (a) the distillery or warehouse? (b) Land on which distillery or warehouse is located?
8. FINANCIAL STATEMENT REQUIRED
COURT BOND JUDICIAL PROCEEDINGS
APPEAL, ATTACHMENT, CLAIM AND DELIVERY,SECURITY FOR COSTS, FORTHCOMING, GARNISHMENT, INJUNCTION,
REPLEVIN,SEQUESTRATION,STAY EXECUTION,SUPERSEDEAS, ETC.
Copy of order, judgment, notice of appeal or other papers necessary for preparation of bond or undertaking,must accompany this
application.
1. Title of Action
(Give names of litigants in full)
2. Date of appointment
3. Court and County or District, in which pending
4. Names and Addresses of Attorneys
(For Plaintiff and Defendant)
5. Amount of Claim or Judgment
IF A PLAINTIFF OR COMPLAINANT STATE THE CIRCUMSTANCES AND THE GROUNDS ON WHICH YOUR ACTION IS BASED.
IF A DEFENDANT STATE THE GROUNDS OF YOUR DEFENSE.
VERY IMPORTANT! INFORMATION AS REQUESTED IN ABOVE INSTRUCTIONS MUST BE GIVEN BELOW.
6. FINANCIAL STATEMENT REQUIRED
WAREHOUSE BOND •
1. Does Applicant own the warehouse?
2. What products are to be stored in the warehouse?
3. Are warehouse receipts issued? Are they numbered?
Who is authorized to issued?
4. How often is an inventory taken?
5. Does Applicant store any grain or products owned personally in the warehouse or elevator?
6. FINANCIAL STATEMENT REQUIRED
87107
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. Financial Statement setting forth assets,..,J liabilities of undersigned as of 19_
ASSETS LIABILITIES
Cash on hand (not in bank) Borrowed money from banks and how
Cash in following banks(give names) secured (if none,write"none")
Stocks&Bonds (attach list) Borrowed money from other sources
Accounts Payable
Stock or material on hand Notes Payable (if none,write"none")
Accounts Receivable •
AReserves for Federal or other Taxes
Notes Receivable Other Reserves
Total Current Assets $ Total Current Liabilities $
REAL ESTATE MORTGAGES ON REAL ESTATE
Parcel No.1 (Market Value) If none,write"none"
a. Description Parcel No. 1
b. In whose name?
c. What did you pay for it?
Parcel No.2(Market Value) Parcel No.2
a. Description
b. In whose name?
c. What did you pay for it?
$ Parcel No.3
Parcel No.3(Market Value)
a. Description
b. In whose name?
c. What did you pay for it?
$ Mortgages on Other Real Estate
Other Real Estate Other Liabilities(if none,write"none")....
Other Assets
Capital
Surplus or Net Worth
Total Assets $ Total Liabilities $
REFERENCES (No Relatives) (Bankers and Merchants preferred)
NAME OCCUPATION ADDRESS
1.
2.
3,
4.
5.
6.
7.
8.
871073
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Tlae'undersigned Applicant and Indemnitor all hereinafter called the Indemnitor(s) here ; certify that the foregoing declarations
made and answers given, are the truth without reservation, and are made for the purpose of inducing THE FETNA CASUALTY AND ...
SURETY COMPANY, of Hartford, Connecticut, hereinafter called the Surety, to become Surety on a certain bond or undertaking
herein applied for, and any renewal of the same, or any bond of a similar nature given in substitution or renewal thereof (all compre-
hended in the word "bond" or "undertaking" as herein used), and in consideration of the Surety executing said bond or bonds do
undertake and agree as follows:
That the Indemnitor(s) will immediately pay the Surety at its Home Office, Hartford, Connecticut,$ , and $
on the day of in each year thereafter,and until the Indemnitor(s) shall serve upon the Surety, at its said office,
competent written legal evidence, satisfactory to the Surety,of its discharge from all such bonds and all liability thereunder.
That the Indemnitor(s) hereby authorize THE /ETNA CASUALTY AND SURETY COMPANY to make such pertinent inquiry as may
be necessary from Financial Institutions; persons, firms, and corporations in order to confirm and verify information referred to or
listed on this application.
The Indemnitor(s) will at all times indemnify, and keep indemnified, the Surety, and hold and save it harmless from and against any
and all damages, loss,costs,charges and expenses of whatsoever kind or nature, including counsel and attorney's fees,whether incurred
under retainer or salary or otherwise,which it shall or may,at any time,sustain or incur by reason or in consequence of its suretyship.
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WITNESS the following signature(s) and seal(s) this 25th day of April 19 87 , homestead and all other exemptions
being hereby expressly waived.
IF APPLICANT (the principal) an individual sign here:
Witness Applicant (Seal)
Witness Applicant (Seal)
Witness Applicant (Seal)
IF APPLICANT (the principal) a co-partnership sign here:
Witness Applicant (Seal)
Name of Firm
By
IF APPLICANT (the principal) a corporation sign here:
Witness WELD �, ApplicantCfa
4�a� By: /• / f C ation
Attest `110-1 l'�' n _ / President
/� County Clerk A Chairman, Boa d County Commissioners
f
car / / t ad IF THIRD PARTY INDEMNITOR(S) sign here:
In consideration of THE /ETNA CASUALTY AND SURETY COMPANY executing the bond hereinabove applied for,we jointly and
severally join in the foregoing indemnity agreement.
Witness Indemnitor (Seal)
Witness Indemnitor (Seal)
Witness Indemnitor (Seal)
Witness Indemnitor (Seal)
Witness • Indemnitor (Seal)
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871073
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