Document 2qwB7q1dQNVevBDXgv3QkrxEp

.. ; ^ Pacific Employers Iasaraacc Ciayuy 1601 Chestnut Street Philadelphia, Pennedvania 19192 TLAINTIIT'S EXHIBIT Cigna. CHV-864 CHEVRON CORPORATION 575 MARKET STREET ROOM 648 SAN FRANCISCO CA 94105 STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY (A stock insurance company) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BEGINNING ON Page Information Page............................... .... ................................................................................................................ i General Section.............................................................................................................................................. \ A The Policy........................................................................................................................................................1 B. Who is Insured .77 ................ .-................................ ........................................................................ 1 C. Workers Compensation Law . ...................................................................... ...............................................1 D. State................................................................................................................................................................. 1 E. Locations...........................................................................................................................................................1 PART ONE-WORKERS COMPENSATION INSURANCE......................................................................1 A How This Insurance Applies . ............................................................................................................... 1 B. We Will Pay.....................................................................................................................................................1 C. We Will Defend...............................................................................................................................................1 D. We Will Also Pay...................... .....................................................................................................................1 E. Other Insurance.............................. 2 F. Payments You MustMake . 2 G. Recovery From Others.............;........................................................................................................................2 H. Statutory Provisions................7,.................................................................................................................... 2 PART TWO-EMPLOYERS LIABILITY INSURANCE.................................................................................2 A How This InsuranceApplies............................................................................................................................. 2 B. We Will Pay.................................. 3 C. Exclusions......................................... 3 D. We Will Defend. . ! !...................................................................................................................................... 3 E. We Will Also Pay...............................................................................................................................................4 F. Other Insurance............................... 4 G. Limits of Liability......................... 4 H. Recovery From Others........................................................................................................................................ 4 I. Actions Against Us................... 4 CKE-3304b Copyright 1991, National Council on Compensation insurance wc 00 00 00 A QUICK REFERENCE - CONTINUED BEGINNING ON Page PART THREE-OTHER STATES INSURANCE................................................................................................. 4 A How This Insurance Applies. . .--................................................................................................................. .4 B. Notice.............................................r.......................................................................................................................4 PART FOUR-YOUR DOTIESIF INJURY OCCURS...........................................................................................5 PART FIVE-PREMIUM...................................................................................................................................................5 A Our Manuals................................... ... ...................................................................................................................... 5 B. Classifications............................................................................................................................................................ 5 C. Remuneration................................... 5 D. Premium^ Payments................... ... ........................................................................................................................ 5 E. Final Premium............................. r;....................................................................................................................... 5 F. Records.......................................-.......................................................................................................................... 5 G. Audit.................................................. 6 PART SIX-CONDITIONS.............................................................................................................................................6 A. Inspection...................................... .......................................................................................................................... 6 B. Long Term Policy......................... r:...........................................................................................................................6 C. Transfer of Your Rights and Duties.......................................................................................................................6 D. Cancelation...................................... . -....................................................................................................................... 6 E. Sole Representative....................................................................................................................................................6 F. Dividend Provisions...................... ........................................................................................................................... 6 IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY. Copyright 1991, National Council on Compensation insurance WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows. GENERAL SECTION A. The Policy This policy includes at its effective date the Infor mation Page and all endorsements and schedules listed there. It is a contract of insurance between you {the employer named in item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy maynot be changed or waived except by endorsement issofd by us to be part of this policy. 3 C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in item 3A of the Information Page. It includes any amendments to that law which are in effect during Hie policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or Hie provisions of any law that provide nonoccupational disability benefits. B. Who is Insured You are insured if you are an employer named in item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces fisted in items 1 or 4 of the Information Page; and it covers all other workplaces in item 3A states unless you have other insurance or are self-insured for such workplaces. FART NE - WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. right to investigate and settle these claims, pro ceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. 1. Bodily injury by accident must occur during the policy period.2 2. Bodily injury by disease must be caused or ag gravated by the conditions of your employment. The employee's last day of last exposure to Hie conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay promptly when due the benefits re quired of you by the workers compensation'law. C. We Will Defend We have the right and duty to defend at our ex pense any claim, proceeding or suit against you for benefits payable by this insurance. We have the D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request but not loss of earnings: 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. 2637 Copyright 1991, National Council on Compensation Insurance Page 1 of e E. Other Insurance H. statutory Provisions We will not pay more than our share of benefits and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers com pensation law including those required because: 1. of your serious and willful misconduct 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discrimi nate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others -We have your rights, and the-rights of persons en titled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you isjurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law. subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A How This Insurance Applies This employers liability insurance applies^'to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or inciden tal to your work in a state or territory listed in item 3A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. 2638 Copyright 1991 National Council on Compensation Insurance Page 2 of 6 B. We Will Pay We will pay all sums you legally must pay as dam ages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is per mitted by law. include damages: -- 1. for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; -- 2. for care and loss of services; and 3. for consequential bodily injury to a spouse, child, parent brother orsister of the injured employee; provided that these damages are thedirect conse quence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. because of bodily injury to your employee that arises out of and in the course of employment claimed against you in a capacity other than as employer. ^ C. Exclusions This insurance does not coven -- -- Tr~ liability assumed under- a contract This exclusion does not apply to a warranty that your work will be done in a workman like manner; 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. bodily injury to an employee while ^employed in violation of law with your actual knowledge of any of your executive officers; 4. any obligation imposed by a workers comp ensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; -- 5. bodily injury intentionally caused or aggravated by you; 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 1" 7. damages arising out or coercion, criticism, demotion, evaluation, reassignment discipline, defamation, harassment humiliation, discrim ination against or termination of any employee, or any personnel practices, policies, acts or omissions. 8. bodily injury to any person in work subject to the Longshore and Harbor Workers' Compen sation Act (33 USC Sections 901-950), the Nonappropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942) any other federal workers or workmen's compensation law or other federal occupa tional disease law, or any amendments to these laws. 9. bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51-60). any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment or any amendments to those laws. 10. bodily injury to a master or member of the crew of any vessel. 11. fines or penalties imposed for violation of federal or state law. 12. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801-1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, pro ceedings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. 2639 Copyright 1991, National Council on Compensation Insurance Page 3 of 6 t. we win Also ray We wilt also pay these costs, in addition to other amounts payable under this insurance, assart of any claim, proceeding or suit we defend; - t. reasonable expenses incurred at our request but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. litigation costs taxed against you; ^ 4. interest on a judgment as required by law until we offer the amount (hie under this insurance; and 5. expenses we incur. F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid, if any insurance or self-insurance is exhausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in item 3.B. of the In formation Page. They apply as explained below. 1. Bodily Injury by Accident The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident A disease is not bodily injury by accident unless it results directly from bodily injury by accident. i. csooiiy injury oy uisease. me tinm snown ior "bodily injury by disease-policy limit" is die most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease-each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include dis ease that results directly from a bodily injury by accident 3. We will not pay any claims for damages after wt have paid the applicable limit of our liability under this insurance. H. Recovery From Others We f ve your rights to recover our payment from anyone liable for an injury covered by this insur ance. 'ou will do everything necessary to protect those ights for us and to help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with ail the terms of this policy; and 2. The amount you owe has been determined with ourconsent or by actual trial and final judg ment This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will lot relieve us of our obligations under this Part PART THREE - OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in item 3.C. of the Information Page. 2. If you begin work in any one of Those states after the effective date of this policy and are not insured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have workon the effective date of this policy in any state not listed in Item 3A. of the Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. Notice Tell us at once if you beginwork in any state listed in item 3.C. of the Information Page. 2640 Copyright 1991, National Council on Compensation Insurance Page 4 of 6 KART PUUIT- T uun lAJIICd ir inwuni Tell us at once it injury occurs that may be covered by this policy. Your other duties are fisted here. 1. Provide for immediate medical and other ser vices required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit 4. Cooperate with us and assist us, as we may request in the investigation, settlement or defense of any claim, proceeding or suit 5. Do nothing after an injury occurs that would in terfere with our right to recover from others. 6. Oo not voluntarily make payments, assume obligations or incur expenses, except at your own cost PART FIVE-PREMIUM A. Our Manuals D. Premium Payments All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications We may change our manuals and apply the clu ges to this policy if authorized by law or a governmental agency re gulating this insurance. B. Classifications Item 4 of the information Page shows the rate and premium basis for certain business or work classi fications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures aW* not properly described by -those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium^ basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Com pensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This para graph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. You will pay all premium when due. You will pay the premium even if part or all of a workers com pensation law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and . work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance, if it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise. 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short rate cancelation table and procedure. Final premium will not be less than the minimum premium. F. Records You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. Copyright 1991, National Council on Compensation Insurance Page 5 of 6 2641 G. Audit You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. PART SIX - CONDITIONS A. Inspection We have the right but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide or the health or safety of your employees or the public. We do not warrant that your workplaces & safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. 2. We may cancel this policy. We must mail or deliver to not less than ten days advance written notice stating when the cancelation is to take effect Mailing that notice to you at your mailing address shown in item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflicts with a law that controls the cancelation of the insurance in this pi icy is changed by this statement to comply with that law. E. Sole Representative B. Long Term Policy If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. The insured first named in Item 1 of the Infor mation Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. F. Dividend Provisions: C. -Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. The following provision applies to any of your operations in states other than California, New York, Oregon, South Carolina and Texas: You are entitled to participate in the distribution of the surplus of the company, as determined by its Board of Directors from time to time. D. Cancelation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect For operations in California, New York, Oregon, South Carolina and Texas, specific endorsements containing provisions applicable to any of these states listed on the Information Page are attached. By signing and delivering the policy to you, we state that it is a valid contract when countersigned by our authorized representative. GEORGE D. MULLIGAN, Secretary PACIFIC EMPLOYERS INSURANCE COMPANY 1601 Chestnut Street Philadelphia, Pennsylvania 19192 c. RICHARD C. FRANKLIN, President Copyright 1991, National Council on Compensation Insurance Page 8 of 6 PREMIUM DISCOUNT ENDORSEMENT Named Insured CHEVRON CORPORATION Endorsement Number Policy Symbol WLR Policy Number C4231805A Issued By (Name of Insurance Company) PACIFIC EMPLOYERS Policy Period Effective Date of Endorsement 03-01-1999 TO 03-01-2000 03-01-1999 Inception Hour for Coverage INSURANCE COMPANY 12:01 AM liMft Hit policy ttirttf. Tli rtmltttr of U iifgnmiiw l la b cf^ltttt Mly wtw dill |$ lmi< tthttgilftl w Hit pftptfttiM of l*t policy. Workers' Compensation and Employers' Liability Policy The premium for this policy and the policies, if any, listed in the Schedule may be eligible for a discount This endorsement shows your estimated discount in the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit Premium subject to retrospective rating is not subject to premium discount _ Schedule of policies and percentages (see reverse side). CKE-3N09 (4/84) Ptd. in U.S.A. 2635 WC 00 04 06 EMPLOYES LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) Named Insured CHEVRON CORPORATION Policy Symbol Policy Number WLR C4231805A Policy Period 03/01/1999 TO 03/01/2000 Endorsement Number Effective Date of Endorsement 03/01/1999 Issued By (Name of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY liiwt tlw policy -->f. T> rtmldr t( MwmIIw (t ta cmI<4 wly wtw tills tudwmmt It lm4 utwyiK It tN amwmlaa tf Hit r*Kcy. Workers' Compensation and Employers' Liability Policy This endorsement applies only to your operations in the State(s) of TEXAS FOR WHICH TOP ARK A OnAT.IFIED SELF-INSURED._______________ * 13 14 15 Part (be-- Workers Compensation Insurance does not apply in these states. Part Two -- Employers Liability Insurance applies in these states as though they were shown in item 3A of the Information Page. Item C -- Exclusions, under Part Two -- Employers Liability Insurance is changed by adding the following: This insurance does not cover: - 13. bodily injury to any member of the flying crew of any aircraft; 14. bodily injury to an employee when you are deprived of common law defenses or are subject to penalty because of your failure to secure your obligations under the workers compensation law of any state shown in the Schedule or otherwise fail to comply with that law. 15. Claims against you if you are subject to the requirements of any workers compensation or occupational disease law and you: -- are deprived of a defense or subjected to a penalty because you fail to make premium payments or to comply with other provisions of the law; or -- are not legally qualified self-insured or a member or subscriber in good standing of a Fund estab lished by a state or other governmental body for workers compensation and occupational disease insurance. 6. Limits of Liability under Part Two--Employers Liability Insurance is replaced by the following: G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in the Schedule. They apply as explained below. 1. Bodily Injury By Accident The limit shown for "Bodily Injury by Accident -- Each Accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident A disease is not bodily injury by accident unless it results directly from bodily injury by accident 2. Bodily Injury By Disease. The limit shown for "Bodily Injury by Disease -- Policy Limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "Bodily Injury by Disease -- Each Employee" is the most we will pay for ail damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. CKE-5N32c (4/92) Ptd. in U.S.A. JWC 99 03 03C EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) COfltiRUMl Limits of Liability Bodily Injury By Accident Bodily Injury By Disease Bodily Injury By Disease _ - $ _ 1,000,000 each accident $ _ 1.000.000 policy limit $ _ 1.000.000 ....... each employee Avtiwnzttf Ayt DESIGNATED WORKPLACES EXCLUSION ENDORSEMENT Named Insured CHEVRON CORPORATION Endorsement Number Policy Symbol WLR Policy Number C4231805A Policy Period Effective Date of Endorsement 03-01-1999 x0 03-01-2000 03-01-1999 Issued By (Name of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY Im.rt lt ptllcy mhi. Tl rtniiider ol t> i>lntlon it H b cowplm ly wbti Milt Hftrawit It lm< stfas.qn.il 1 ttw pftpyMfqt ( |> p.llcy. Workers' Compensation and Employers' Liability Policy The policy does not cover work conducted at or from: ANY PLACE IN ANY STATE OTHER THAN TEXAS. CKE-3N14 (4/84) Ptd. in U.S.A. Copyright 1982-83. National Council on Compensation Insurance WC 00 03 02 CONTINGENT EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT Named Insured CHEVRON CORPORATION Endorsement Number Policy Symbol Policy Number WLR C4231805A Policy Period Effective Oate of Endorsement 03-01-1999 TO 03-01-2000 03-01-1999 issued By (Name of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY laurt It* pllcy Mutw. TU rii<f ol tin lnl.nmtlM it lo l> Cfplt< ly > Hit n<ornmm Is lm< utmml l Hit {tr.pir.tlM at Mw pulley. Workers' Compensation and Employers' Liability Policy The premium for this policy wifi be adjusted by an experience rating modification factor. The factor shown in the schedule is a Contingent Experience Rating Modification factor based on the appropriate experience data available and replaces any prior experience modification factor. We will issue an endorsement to show a revised factor if appropriate additional experience data becomes available. The Contingent factor will apply unless a revised factor is subsequently issued. SCHEDULE 0.460 CKE-1700 (1/90 ) Ptd. in U.S.A. 2G07 Copyright 1989- National Council on Compensation Insurance. WC 00 04 12 CANCELATION BY US Named Insured CHEVRON CORPORATION Policy Symbol Policy Number WLR C4231805A Policy Period 03-01-1999 jo 03-01-2000 Issued By (Name of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY Endorsement Number Effective Date of Endorsement 03-01-1999 Inception Hour for Coverage 12:01 AM lsft Mi policy rnmbtr. Tin rnul<r of flu Irfamwlw is fa g caniplmd oly > Hilt iriofwiil It imt< a>inn 1 flu prfft<i ( 1> plicy. Workers' Compensation and Employers' Liability Policy Paragraph 2 of Condition D. Cancelation is replaced by the following: 2. We may cancel this policy. We must mail or deliver to yo< not less than the number of days advance written notice shown in the schedule below . ating when the cancelation is to take effect Mailing that notice to you at your mailing address shown in item 1 of the Information Page will be sufficient to prove notice. Schedule a. 10 days it.we cancel for nonpayment of premium; or b. 60 days if we cancel for any other reason. CKE-8685 (9/91) Ptd. in U.S.A. Z603 _ WC 99 06 35 MAMED INSURED ENDORSEMENT Named Insured CHEVRON CORPORATION Policy Symbol Policy Number WLR C4231805A Policy Period 03-01-1999 TO 03-01-2000 Effective Date of Endorsement 03-01-1999 Issued By PACIFIC EMPLOYERS INSURANCE COMPANY The above is required to be completed only wtiee thfc endorsement is issued subsequent to the preparation o< the poWcy. WE AGREE WITH YOU THAT ITEM 1, THE INSURED, OF THE INFORMATION PAGE IS AMENDED TO READ AS FOLLOWS: NAME FEIN NO. CHEVRON CORPORATION CHEVRON U.S.A. INC. " CHEVRON CHEMICAL COMPANY (CCC & PLEXCO) CHEVRON CHEMICAL INTERNATIONAL SALES, INC CHEVRON PIPE LINE COMPANY CHEVRON SHIPPING COMPANY CHEVRON STATIONS INC. 94-0890210 25-0527925 94-0361642 94-1542524 94-1529160 94-1379957 84-0618607 AND ANY EXISTING, ACQUIRED OR NEWLY FORMED ENTITY IN WHICH THE NAMED INSURED HAS A 50Z OR MORE OWNERSHIP INTEREST. -- AGENT: JSH MARSH MCLENNAN SERVICE OFFICE: SFU 2613 WC 99 9999 AMENDATORY ENDORSEMENT Named Insured CHEVRON CORPORATION Policy Symbol WLR Issued By Policy Number :4231805A PACIFIC Policy Period 03-01-1999 TO 03-01-2000 EMPLOYERS INSURANCE COMPANY Effective Date of Endorsement 03-01-1999______ The above is required to be completed only when this endorsement is issued subsequent to the preparation of the policy. Item 1 of the information Page, The Insured, is extended as follows: SCHEDULES OF FDRMS AND ENDORSEMENTS WC000302 - DESIGNATED WORKPLACE EXCLUSION ENDORSEMENT WC990302B - VOLUNTARY COMPENSATION ENDORSEMENT FOREIGN WC990303C - EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) WC990635 - CANCELATION BY US ENDORSEMENT WC999999 - NAMED INSURED ENDORSEMENT AGENT: JEH MARSH MCLENNAN SERVICE OFFICE: SFU 2611 (Authorized Agent) WC 99 99 99 TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Named Insured CHEVRON CORPORATION Policy Symbol Policy Number WLR C4231805A Policy Period 03-01-1999 JO 03-01-2000 Endorsement Number Effective Date of Endorsement 03-01-1999 Issued By (Name of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY lsrt l> p>Hcy wbir. n ram<r a) Bit iifanmlM l l coplm ly wt ttls m<wswiiil It iairi M>mHt f Hw fttpuni-- f Hu ftllcy. Workers' Compensation and Employers' Liability Policy This endorsement applies only to the insurance provided by the policy because Texas is shown in item 3A of the Information Page. We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule, but this waiver applies onl\ with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule I. ( ) Specific Waiver Name of person or organization: 1_X ) Blanket Waiver _ Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. "BLANKET (WHEN REQUIRED BY CONTRACT, IN WRITING PRIOR TO LOSS)." 2. Operations: TM 3. Premium: -- The premium charge for this endorsement shall be percent of the premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium: _ 5. Advance Premium: $0 CKE-7N7Ba (10/84) Ptd. in U.S.A. Z577 ^ WC 42 03 04 DIVIDEND PROVISION (TEXAS) Named Insured CHEVRON CORPORATION Endorsement Number Policy Symbol Policy Number WLR C4231805A Policy Period Effective Date of Endorsement 03-01-1999 JO 03-01-2000 03-01-1999 Issued By (Name of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY lsrt Hit policy llrtif. Tit rnnil<r tl Hu lifamitltt l l 1 wly > Milt wfcnwwt It lll< u t> titfctUn < 1> polity. Workers' Compensation and Employers' Liability Policy You are entitled to participate in a distribution of the surplus of the Company, as determined by its Board of Directors from time to time, after approval in accordance with the provisions of the Texas Insurance Code, of 1951, as amended. CKE-7N80 (7/84) Ptd. in U.S.A. Z6Z7 VVC 99 06 08 DEDUCTIBLE NOTICE OF ELECTION TO ACCEPT TEXAS WORKERS' COMPENSATION BENEFITS Named Insured CHEVRON CORPORATION Endorsement Number Policy Symbol Policy Number WLR C4231805A Policy Period Effective Date of Endorsement: 03-01-1999 TO 03-01-2000 03-01-1999 Issued By (Name of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY lrt lli pillcy mmbir. Tin remit<r if lit iiltmutioi It l H cafll< wly > His Iidwimm is Iuiri l Bit >r>KHin tf Bit policy. Workers' Compensation and Employers' Liability Policy Texas law permits an employer to obtain Workers' Compensation insurance with a deductible. The insurance applies only to benefits payable under Texas Workers' Compensation Law. When a deductible is elected, the policyholder is required to reimburse the insurance carrier for benefits payable under the law up to the deductible amount and a credit is applied to the policy. Premium credits are determined based on the deductible selected, and the hazard group. The hazard group is determined by the classification that produces the largest amount of estimated Texas standard premium. You are not required to choose a deductible. If you do choose one, your insurance company will pay the deductible amount for you. but you must reimburse the insurance company within 30 days after they send you notice that payment is due. If you fail to reimburse the insurance company, they may cancel the policy, upon ten days written notice, and any resulting premium may be applied to the deductible amount owed. If a deductible amount is desired, please indicate below. Yes, I want a deductible of: (select only one) '""1. 2. 3. $per accident $ annual ^aggregate $/$ per accident/annual aggregate applied to benefits payable under the Texas Workers' Compensation Law. I understand that the company will pay the deductible amount and seek reimbursement (monthly, quarterly or other) 2629 POLICY INFORMATION PAGE ENDORSEMENT Named Insured CHEVRON CORPORATION | Endorsement Number Policy Symbol WLR Policy Number C4231805A Policy Period 1 Effective Date of Endorsement 03-01-1999 TO 03-01-2000| 11-01-1999 Issued By (fame of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY Imit l> policy aaiatat. T> riCr at ih ialtnaatiaa is la ba caflataQ aaly rlw IH t4tftttM it iiml Mtwfwil tt tta prafaratlaa *t l*t Hcy Workers' Compensation and Employers' Liability Poiioy The following item(s) Insured's Name (WC 89 06 01) Q Item 3A States (WC 89 06 11) Policy Number (WC 89 06 02) Effective Date <WC 89 06 03) Q Item 3J3. Limits (WC 89 06 12) G Item 3.C. States (WC 89 06 13) Expiration Date (WC 89 06 04) 0 Insured's Mailing Address (WC 89 06 05) G Experience Modification (WC 89 04 06) G Producer's Name (WC 89 06 07) G Change in Woricpiace(s) of Insured (WC 89 06 08) G Insured's Legal Status (WC 89 06 10) is changed to read: = Q Item 3D. EndorsementNumbers (WC 89 06 14) 0 Item 4. * Class, Rate, Other (WC 89 04 15) G Audit Frequency (WC 89 04 16) G Carrier Servicing Office (WC 89 06 17) G Interstate/Intrastate Risk ID. Number (WC 89 06 18) G Carrier Name and Number (WC 89 06 19) IN CONSIDERATION OF PREMIUM TO BE ADJUSTED BY AUDIT, YOUR POLICY IS AMENDED TO READ AS PER THE ATTACHED SCHEDULE: INSUREDS MAILING ADDRESS: - 6001 BOLLINGER CANYON ROAD, E1208B SAN RAMON, CA 94583-0722 *See next page for Item 4. changes, if any. _INSURED'S COPY CKE-1U76 Ptd. in U.S.A. 1QRI17 Copyright 1987 National Council on Comparuation Insuranca. (PAGE 1 LAST PAGE) WC-99 06 00 A 01-10-2000 SFU POLICY INFORMATION PAGE ENDORSEMENT Named Insured CHEVRON CORPORATION Endorsement Number Policy Symbol Policy Number WLR C4231805A Policy Period Effective Date of Endorsement 03-01-1999 TO 03-01-2000 03-01-1999 Issued By (Name of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY lasatt ilw policy mulur. m rni<r aI l> is lo coplt< <ly n>t His ntoiMinl l isstti t t>< fftfiittif ol l> policy. Workers' Compensation and Employers' Liability Policy The following item(s) Insured's Name (WC 89 06 01) Policy Number (WC 89 06 02) Effective Date (WC 89 06 03) Expiration Date (WC 89 06 04) G Insured's Mailing Address (WC 89 06 05) [Xl Experience Modification (WC 89 04 06) Producer's Name (WC 89 06 07) G Change in Workplace(s) of Insured (WC 89 06 08) G Insured's Legal Status (WC 89 06 10) is changed to read: G Item 3A States (WC 89 06 11) Q Item 3J3. Limits (WC 89 06 12) Q Item 3. States (WC 89 06 13) G item3D. Endorsement Numbers (WC 89 06 14) 0 Item 4. * Class, Rate, Other (WC 89 04 15) Q Audit Frequency (WC 89. 04 16) G Carrier Servicing Office (WC 89 06 17) Q Interstate/Intrastate Risk ID. Number (WC 89 06 18) G Carrier Name and Number (WC 89 06 19) IN CONSIDERATION OF PREMIUM TO BE ADJUSTED BY AUDIT, YOUR POLICY IS AMENDED TO READ AS FOLLOWS: INTERSTATE EXPERIENCE MODIFICATION FACTOR IS AMENDED TO READ: 0.4500 FOR THE FOLLOWING STATES: TX THIS EXPERIENCE MODIFICATION FACTOR IS EFFECTIVE 03-01-1999 TO 03-01-2000 AND IS FINAL. - *See next page for Item 4. changes, if any. INSURED S COPY CKE-1U76 Ptd. in U.S.A. H715 Copyright 1987 National Council on Compensation Insurance. (PAGE 1 LAST PAGE) WC 99 06 00 A 11-19-1999 SFU VOLUNTARY COMPENSATION ENDORSEMENT FOREIGN Named Insured CHEVRON CORPORATION Endorsement Number Policy Symbol Policy Number WLR C4231805A Policy Period Effective Date of Endorsement 03-01-J999 TO 03-01-2000 03-01-1999 Issued By (Nome of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY lft tin p(tcy mtw. nit imiito nf li iriwWlw it tnir~caeplt<d wly irliH m irtxuwK it ItstH ( tta fftfUMiH tt t> ptUty. Workers' Compensation and Employers' Liability Policy This endorsement adds Foreign Voluntary Compensation Insurance to the Policy. A. How this Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by a person who is your employee included in the group of employees described in the Schedule. 2. The bodily injury must occur in the course of the insured employee's employment by you in the country or countries designated in the Schedule or while being transported to or from die United States of America, its territories or possessions, or Canada, and the employment must be necessary or incidental to work in a country listed in the Schedule. 3. This insurance applies only to employees you hire within the limits of the United States of America while they are traveling or temporarily residing outside the United States of America, its territories or possessions or Canada for a period no longer than thirty days. 4. We will reimburse you for the benefits required by this endorsement if we are not permitted to pay the benefits directly to persons-entitled to them. B. We will Pay 1. We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers' compensation law shown in itme 1 of the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. 2. Provided a separate specific premium's charged and indicated, we will pay such additional expenses as reasonably may be incurred over and above normal transportation costs for repatriation of employees suffering from bodily injury or diseases covered by this endorsement (including the bodies of employees injured fatally) from a Designated Country to a destination in the United States of America or Canada provided that such injuries make repatriation necessary in the opinion of competent medical authorities. Our liability is limited to the amount shown in the schedule with respect to any one employee. C. Exclusions ^ This insurance does not coven 1. Any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. Bodily injury intentionally caused or aggravated by you. 3. Any obligation imposed by the United States Longshoremen's and Harbor Workers' Compensation Act 4. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950), the Non-appropriated Fund Instrumentalities Act (5 USC Sections 8171-8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331-1356), the Defense Base Act (42 USC Sections 1651-1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901-942) any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws. CKE-5E84b (6/97) Ptd. in U.S.A. 2553 WC 99 03 028 C. Exclusions (Continued) 5. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51-60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment or any amendments to those laws. 6. Bodily injury to a master or member of the crew of any vessel. D. Before We Pay Before we pay benefits to the persons entitled to them, they must 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E. Recovery Ft m Others If we make: a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it If the persons entitled to the benefits of this instance make a recovery from others, they must reimburse us for the benefits we paid them. F. Employers Liability Insurance Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the country shown in the Schedule were shown in item 1A of the information Page. A. Employees ANY UNITED STATES EMPLOYEES WHILE TEMPORARILY OUTSIDE THE UNITED STATES OR CANADA WHILE ON BUSINESS. SCHEDULE ^Designated Country and/or Location of Operations ANYWHERE IN THE WORLD BUT EXCLUDING: 1. THE UNITED STATES OF AMERICA (INCLUDING ITS TERRITORIES AND POSSESSIONS) AND PUERTO RICO; 2. ANY COUNTRY OR JURISDICTION WHICH IS THE SUBJECT OF TRADE OR ECONOMIC SANCTIONS IMPOSED BY THE LAWS OR REGULATIONS OF THE UNITED STATES OF AMERICA. Designated Workers' Compensation Law TEXAS B. REPATRIATION LIMIT $ 100.000 CKE-5E84b (6/97) Ptd. in U.S.A. 2554 - WC 99 03 02B NEGOTIATED DEDUCTIBLE ENDORSEMENT STATE OF TEXAS Named Insured CHEVRON CORPORATION Endorsement Number Policy Symbol Policy Number WLR C4-231805A Policy Period Effective Date of Endorsement 03-01-1999 to 03-01-2000 03-01-1999 Issued By (Name of insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY lattrt Hit policy nmkw. T> rl<r ol l> iriwitlM l ( >i coaltt< ly w> Hit <iii< Is iiai< irtmw* U l> prarmi W ttt Mllcy. Workers' Compensation and Employers' Liability Policy 1. This agreement is between you and us. it does not change the rights of others under this Policy. 2. We will pay aid you will reimburse us for all payments we make on your behalf as benefits under Part One - Workers Compensation Insurance of this Policy or as damages under Part Two - Employers Liability Insurance of this Policy up to the amount of the Deductible as shown in the Schedule. 3. When used in this Endorsement -- "Incident Deductib 1 Limit" shall mean the amount of benefits or damages because of (a) bodily injury by disease applied separately to each employee or (b! bodily injury by accident applied separately to each occurrence, to which this insurance applies and for which you have a duty to reimburse us wider this Policy. "Aggregate Deductible Limit" shall mean the most you must reimburse us for the sum of all benefits or damages to which this insurance applies. -- 4. We will provide investigation, administration, adjustment and settlement services, and shall provide the defense of claims or suits for which this Policy provides coverage. 5. You will reimburse us for all expenses, costs and interest which we pay in connection with the investigation. TTBfninistration, adjustment settlement or defense of any claim or suit arising from coverages under this Policy. Check one box only: lx 1 These expenses, costs and interest are separate from, and in addition to, the Incident Deductible Limit and the Aggregate Deductible Limit shown below in the Schedule in Paragraph 10. ( | These expenses, costs and interest are part of, and included in, the Incident Deductible limit and the Aggregate Deductible Limit shown below in the Schedule in Paragraph 10. 6. You will also reimburse us for all assessments which are not included in the Policy premium that we may incur including those based on the total amounts associated with the Deductible obligation of this Endorsement These assessments are also separate from, and in addition to. the Aggregate Deductible Limit shown below in the Schedule in Paragraph 10. 7. Under Part Two - Employers Liability Insurance, the terms of this Policy, including those with respect to (a) our right and duty with respect to hie defense of suits and (b) your duties in the event of an injury, apply irrespective of the application of any Deductible Amount The applicable limits of liability shall be reduced by the amount of any damages within any Deductible Amount 8. If this Policy is cancelled, the Aggregate Deductible Limit shown (if any) in the Schedule will be reduced to a pro-rata amount based on the time this Policy was in force.9 9. Paragraph D. Cancelation of PART SIX -^CONDITIONS of the Policy is extended to include the following Item 5: 5. If you fail to deliver an amended or additional or substitute collateral required by us to secure your obligations under this Deductible Endorsement or if you fail to reimburse us for any of your obligations under this Deductible Endorsement we may cancel this Policy in accordance with items 2, 3. and 4. above. ^ CKE-6E45c (10/97) Ptd. in USA (Continued on Reverse Side) WC 99 06 80A Incident Deductible Limit $___________ $21 OOP ,000 SCHEDULE Aggregate Deductible Limit $ 10. All terms, conditions, and limitations of this Policy not inconsistent with this Endorsement continue to apply. Named insured: CHEVRON CORPORATION________________________________________________ Accepted and Agreed to by:. CKE-6E45c (10/97) Ptd. in USA WC 99 06 80A TEXAS AMENDATORY ENDORSEMENT Named Insured CHEVRON CORPORATION Endorsement Number Policy Symbol WLR Policy Number C4231805A Policy Period Effective Date of Endorsement 03-01-1999 to 03-01-2000 03-01-1999 Issued By (Name of Insurance Company) PACIFIC EMPLOYERS INSURANCE COMPANY lift Ui policy mwtur. T> rtmiiUtr al ttc nfitmtiM It to N cfplitit ly wlw ttl il!^ors<wX It iimt atmml It t> trtpanlitt of Bn ptllcy. Workers' Compensation and Employers' Liability Policy This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3A of the Information Page. GENERAL SECTION B. Who Is Insured is amended to read: You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership or joint venture, and if you are one of its partners or members, you are insured, but only in your capacity as an employer of the partnership's ^r joint venture's employees. D. State is amended to read: State means any state or territory of the United States of America, and the District of Columbia. PART ONE --WORKERS COMPENSATION INSURANCE E. Other Insurance is amended by adding this sentence: This Section only applies if you have other insurance or are self-insured for the same loss. F. Payments You Must Make This Section is amended by deleting the words "workers compensation" from number 4. H. Statutory Provisions This Section is amended by deleting the words "after an injury occurs" from number 2. PART TWO -- EMPLOYERS LIABILITY INSURANCE C. Exclusions Sections 2 and 3 are amended to add: This exclusion does not apply unless the violation of law caused or contributed to the bodily injury. Section 6 is amended to read: 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America, Mexico or Canada who is temporarily outside these countries. D. We Will Defend This Section is amended by deleting the last sentence. PART FOUR -- YOUR DUTIES IF INJURY OCCURS Number 6 of this part is amended to read: 6. Texas law allows you to make weekly payments to an injured employee in certain instances. Unless authorized by law, do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. -- CKE-7N74f (3/97) Ptd. in U.S.A. 2621 Page 1 of 3 WC 42 03 01E PART FIVE --PREMIUM A. Our Manuals is amended by adding this sentence: In this part "our manuals" means manuals approved or prescribed by the State Board of Insurance. C. Remuneration Number 2 is amended to read: ^ 2. All other persons engaged in work that would make us liable under Part One (Workers Compensation Insur ance) of this policy. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured workers compensation insurance. E. Final Premium Number 2 is amended to read: 2. If you cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. PART SIX --CONDITIONS A. Inspection is amended by adding this sentence: Your failure to comply with the safety recommendations made as a result of an inspection may cause the policy to be canceled by us. -- C. Transfer of Your Rights and Duties is amended to read: Your rights and duties under this policy^ may not be transferred without our written consent If you die, coverage will be provided for your surviving spouse or your legal representative. This applies only with respect to their acting in the capacity as an employer and only for the workplaces listed in Items 1 and 4 on the Information Page. D. Cancelation is amended to read: 1. You may cancel this policyT You must~mail or deliver advance notice to us stating when the cancelation is to take effect = 2. We may cancel this policy. We may also decline to renew it We must give you written notice of cancelation or nonrenewal. That notice will be sent certified mail or delivered to you in person. A copy of the written notice will be sent to the Texas Workers Compensation Commission. 3. Notice of cancelation or nonrenewal must be sent to you not later than the 30th day before the date on which the cancelation or nonrenewal becomes effective, except that we may send the notice not later than the 10th day before the date on which the cancelation or nonrenewai becomes effective if we cancel or do not renew because of: a. Fraud in obtaining coverage; b. Failure to pay a premium when payment was due; c. An increase in the hazard that results from an action or omission and that would produce an increase in the rate, including an increase because of failure to comply with reasonable recommendations for loss control or to comply within a reasonable period with recommendations designed to reduce a hazard that is under your control; d. A determination by the Commissioner of Insurance that the continuation of the policy would place us in violation of the law, or would be hazardous to the interests of subscribers, creditors, or the general public. -- 4. If another insurance company notifies the Texas Workers Compensation Commission that it is insuring you as an employer, such notice shall be'a cancelation of this policy effective when the other policy starts. CKE-7N74f (3/97) 2622 Page 2 of 3 WC 42 03 01E Part Sovan has been added as follows: PART SEVEN -- OUR DUTY TO YOU FOR CLAIM NOTIFICATION A. Claims Notification We are required to notify you of any claim that is filed against your policy. Thereafter we shall notify you of any proposal to settle a claim or, on receipt of a written request from you, of any administrative or judicial proceeding relating to the resolution of a claim, including a benefit review conference conducted by the Texas Workers' Compensation Commission. You may in writing, elect to waive this notification requirement We shall, on written request from you, provide you with a list of claims charged against your policy, payments made and reserves established on each claim, and a statement explaining the effect of claims on your premium rates. We must furnish the requested information to you in writing no later than the 30th day after the date we receive your request The information is considered to be provided on the date the information is received by the United States Postal Service or is personally delivered. COMPLAINT NOTICE SHOULD ANY DISPUTE ARISE ABOUT YOUR PREMIUM OR ABOUT A CLAIM THAT YOU HAVE FILED. CONTACT THE AGENT OR WRITE TO THE COMPANY THAT ISSUED THE POLICY. IF THE PROBLEM IN NOT RESOLVED, YOU MAY ALSO WRITE THE STATE BOARD OF INSURANCE PJ3. BOX 149091. AUSTIN, TEXAS 78714-9091. FAX# <512) 475-1771. THIS NOTICE OF COMPLAINT PROCEDURE IS FOR INFORMATION ONLY AND DOES NOT BECOME A PART OR CONDITION OF THIS POLICY. CKE-7N74f (3/97) Authorized Agent Page 3 of 3 WC 42 03 01E LEONARD W. RILEY, JR. EXECUTIVE DIRECTOR TEXAS WORKERS' COMPENSATION COMMISSION SOUTHFIELD BUILDING, MS-96,4000 SOUTH IH-35, AUSTIN, TEXAS 78704-7491 (512) 448-7900 STATE OF TEXAS COUNTY OF TRAVIS CERTIFICATION OF SPECIFIED INSTRUMENT'S) I, Rachel Solis, Data Entry Operator and Custodian of the Records of the Texas Workers' Compensation Commission of the State of Texas, DO HEREBY CERTIFY that the attached are complete copy's of the TWCC 20's(Insurance Carrier Notice of Coverage/Cancellation/Non-Renewal of Coverage), TWCC 20A's(Correction/Revision/Endorsement to Existing Policy) and TWCC 205's(Locations of Employers' Business(es) for 1999 to 2001 for: 1_ Chevron Corporation MBI #902587200 I FURTHER CERTIFY that I am the lawful possessor and custodian of the records of the Texas Workers' Compensation Commission of the State of Texas. IN TESTIMONY WHEREOF, I have officially affixed my name and caused'to be impressed hereon the seal of the Texas Workers' Compensation Commission at 4000 South IH-35, in the City of Austin, Texas on this 14th day of November, 2000. ~ "This document is signed under the authority delegated to me by Leonard W. Riley, Jr., Executive Director, pursuant to the Texas Workers' Compensation Act, Texas Labor Code Sections 402.041-402.042." Rachel Solis, Insurance Coverage Department Tex. Lab, Code 402.042, 402.081. Do not remove any of the records or detach this certification page. These actions nullify the certification. An Equal Opportunity Employer Check one: Correction CORRECTION/REVISION/ENDORSHWrE^nTneWSyntoptooict------ Revision 0 Endorsement ^-Effective Data nf Change _ 03/01/200 The current policy is hereby amended (State only what is being amended:-) Adding Locations and Amending Address of Insured. Name of Insurance Carrier: Pacific Emolovers Insurance Co. Name of Primary Insured: Chevron Corporation Address of Primary Insured: 6001 Bollinger Canyon Road Building E - 2nd Floor San Ramon, CA 94583 I NCCI Number 10677 FEIN Number 940890210 Policy Number C42835584 Effective Date of P. icy (mm-dd-yy) 03/0 /2000 End Date of Policy (mm-dd-yy) 03/01/2001 Date Carrier Notifie , Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS ChecJfOne: [2* 03/01/2000 DELETE 940890210 Federal Tax ID Number______________________ Number of Employees_______ 0~200_______ Name________________ Address Warehouse City DallasState __JX_ Zip 252kL Check one: ADD ! Fffactive Data 03/01/2000 DELETE Federal Tax ID Number 940890210__________ _ Number of Employees. 0-200 Name Address 9150 Royal Lane ^ X City. Irving J____ State TjflJTzip. Check one: HI ADD Effective Date _____0__3_/_0__1/2am DELETE Federal Tax ID Number______ 940890210 Number of Employees. 0-200 TWCC 20A (Rev. 10/93) Page l=of 10 Name Address 221 N. Main City. Euless State TX Zip 76039 1LXAS V/CRKCRS' COWiT.NS/'TION COMMISSION Check one: Correction CORRECTION/REVISION/ENDORSEMENT Revision 12 Endorsement FffactK/ft Data of Channe The current policy is hereby amended (State only what is being amended:-) Adding Locations and Amending Address of Insured. 03/01/2000 Name of Insurance Carrier: Pacific Emnlnvpra Tnsnranra r.n Name of Primary Insured: Chevron Corporation Address of Primary Insured: 6001 Bollinger Canyon Road Building E - ''nd Floor San Ramon, CA 94583 ~ _ ,: NCCI Number 10X77 ... FEIN Number 940890210 Policy Number ' C42835584 -- Effective Date of Policy (mm-dd-yy) 03/01/2000 End Date of Policy (mm-dd-yy) 03/01/2001 Date Carrier Notified Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check one: GO AQO Effective Date 03/01/200(L_ DELETE 940890210 Federal Tax ID Number______ Number of Employees 0-200 Name ______------------------------------------------------------Address 3394 S. Watson Rd.\_^L r:ity ArlingtonState TX . Zip , 76Q1A Check one: HI ADD Effective Data 03/01/2000 DELETE Federal Tax ID Number 940890210_______ Number of Employees_________ 0-200______ = Check one: DO ADD Effective Date 03/01/20(10 DELETE Federal Tax ID Number______ 940890210 -- Number of Employees_______~200_______ - Name______________ -- Address 6100 Alma City Plano State TX TWCC 20A (Rev. 10/93) Rage 2 of 10 TC/AS VvGRKLRS' COMPENSA TION COMMISSION C0RRECT10N/REVTfc>l0N/fctML>0RSnSlgfEiN I I U H-JUS I 'HUCi. PUUL'f Check one: Correction Revision 0 Endorsement Effective Date of Change------03/01/2000 The current policy is hereby amended (State only what is being amended:-) Adding Locations and Amending Address of Insured. Name of Insurance Carrier: Pacific Employers Insurance Co. Name of Primary Insured: Chevron Corporation Address of Primary Insured: 6001 Bollinger Canyon Road Building E - 2nd FIoor San Ramon, CA 94513 -- 1 " NCCI Number 10677 FEIN Number 940890210 Policy Number a2835584 Effective Date of Policy (mm-dd-yy) 03/01/2000 End Date of Policy (mm dd-yy) 03/01/2001 Date Carrier Notified Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check one: Aoe DELETE . cEwffect..ive Dn a.te___o__a_/_i_?_i_/_2_o__o_o_ __ 940890210 Federal Tax ID Number. Number of Employees___________ 0-200 Name -.... Address 7651 Campbell Rd. CityQaiiasState--XX----- Zip --L22AR Check one: ADD Effective Date 03/01/2000 DELETE Federal Tax ID Number 940890210 Number of Employees_______ 0-200________ ~ Check one: 0 ADD Effective Date 03/01/2000^ DELETE Federal Tax ID Number 940890210______-- Number of Fmplnyees 0-200__________ TWCC 20A (Rev. 10/93) Address 3080 S. Jupiter City GarlandState _XX_____________Zip ,, ZJLQA1 10 TEXAS WOlll'KHS' COW'ENSA 7ION COMMISSION Check one: Correction Revision El Endorsement ^ Fffectiwi Data nf Change The current policy is hereby amended (State only what is being amended:-) Adding Locations and Amending Address of Insured. 03 /o l / 2000 Name of Insurance Carrier: Pacific Employers Insurance Co. Name of Primary Insured: Chevron Corporation Address of Primary Insured: 6001 Bollinger Canyon Road Building E - 2nd Floor San Ramon, CA 94583 -- _1 __ 37 NCCI Number 10677 FEIN Number 940890210 Policy Number c42835584 Effective Date of Policy (mm-dd-yy) 03/01/2000 End Date of Policy (mm-dd-yy) 03/01/2001 Date Carrier Notified Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check one: ra U3 aATU5U5 DELETE . 037-01/2000 Effective Date_______________ __ 940890210 Federal Tax ID Number_______________________-- Number of Fmpinyftns 0-200 Name .......- - Address 9446 Garland Rd. City Dallas__ ______ Stated Check one: 0 Effective Date 03/01/2000 _ DELETE Federal Tax ID Number 940890210 _ Number Of Fmplnynes 0-200___________ Check one: IM ADD Effective Date 03/01/20OT DELETE Federal Tax ID Number 940890210 r Number of Fmployaes 0-200___________ Address 501 W. Beltline City Richardson State TX Zip ... Z5Q&Q. TWCC 20A (Rev. 10/93) Page 4 of 10 tf-VAS WORKERS' COMPENSATION COMMISSION unecK one: O Correction CORRECTION/REVISION/ENDORSEMENT^^EXI^n!^; POLICY " Revision 0 Endorsement Effective Date of Change. 03/01/2000 The current policy is hereby amended (State only what is being amended:-) Adding Locations and Amending Address of Insured. Name of Insurance Carrier: Pacific Employers Insurance Co. ^ = Address of Primary Insured: 6001 Bollinger Canyon Road Building E - 2nd Floor San Ramon, CA 94583 ^ NCCI Number 10677 reiNNum90210 Policy Number C42835584 Effective Date of Policy___ (mm-dd-yy) 03/01/2000 End Date of Policy (mm-dd-yy) 03/01/ 2001 Date Carrier Notified Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check one: HQ ADD DELETE oa/p1/2000 Effective Date_______________ 940890210 Federal Tax ID Number Number of Employees 0-200 Name_____________ ___ -........ Address 7909 Spring Valley City. Dallas state TX Zip 75240. Check one: 0 ADD EffectiveDate 03/01/2000^ DELETE Federal Tax ID Number 940890210______ _ Number of Employees 0-200____________ _ Name .ai v ^ Address 101 W. qaairSel^ Rd. , \ Pjty Richardson \ 3^' Zip 75080 Check one: 0 ADD Effective Date 03/01/20003 DELETE Federal Tax ID Number = 940890210______ _7_ Number of Employees 0~200__________ Name_____________________ Address 3700 Highway 67 mty Mesquite ........StateIX______ Zip 75149 'WCC 20A (Rev. 10/93) Page 5 of 10 TEXAS WORKERS' COMPENSATION COMMISSION Check one: Correction CORRECTlON/REVISION/ENDORSEMeNTTOExISS Revision 0 Endorsement Effective Date of Change. The current policy is hereby amended (State only what is being amended:-) Adding Locations and Amending Address of Insured. 03/01/2000 Name of Insurance Carrier: Pacific Employers Insurance Co. Name of Primary Insured: Chevron Corporation ~ Address of Primary Insured: 6001 Bollinger Canyon Road Building E - 2nd Floor San Ramon, CA 94583 NCCI Number 10677 FEIN Number 940890210 Policy Number C42835584 Effective Date of Policy (mm-dd-yy) 03/01/2000 End Date of Policy (mm-dd-yy) 03/01/2001 Date Carrier Notified Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check one: (x]^DD DELETE Effective Date 03/01/2000 _______ ^ZZL 940890210 _ Federal Tax ID Number Number of Employees. Name____________________ Address 2332 ff. Davis PHy Dallas State ^ Zip 75208 Check one: 0 AD0 Effective Date 03/0l/2Mff DELETE -- Federal Tax ID Number 940890210 Number of Employees 0-200________ Check one: . (3 ADD Effective Date , 9.U91//?.009------------ DELETE Federal Tax ID Number 940890210 Number of Employees0-200 ____________________ Name_______ _______--------------------------------------------Address 400 South Marsalis "" _____________________________________-- ---------- Pity DallasState_J2_____________ Zip --75203. T'.VCC 20A (Rev. 10/93) Page 6 of 10 TEXAS WORKERS' COMPENSATION COMMISSION Check one: Cl Correction CORRECTION/REVISION/ENDORSement to E3 C Revision Q Endorsement Effective Date of Change. The current policy is hereby amended (State only what is being amended:-) Adding Locations and Amending Address of Insured. 03/01/2000 Name of Insurance Carrier: Pacific Employers Insurance Co. Name of Primary Insured: Chevron Corporation Address of Primary Insured: 6001 Bollinger Canyon Road Building E - 2nd Floor San Ramon, CA 94583 ^ Vt NCCI Number 10677 FEIN Number 940890210 Policy Number C42835584 Effective Date of Policy (mm-dd-yy) 03/01/2000 End Date of Policy (mm-dd-yy) 03/01/2001 Date Carrier Notified Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check one: [x] ADD Effective Date Q.3./01/2000 DELETE 940890210 Federal Tax ID Number______ Number of Employees 0-200 Name_____________________ _____ Address 8235 S. Hampton Rd. City. Dallas State TX Check one: ADD Effective Date 03/01/2000 - DELETE Federal Tax ID Number 940890210______ ^ Number of Employees Q~200___________ Check one: ADD ^Effective Date 03/01/2000 ~ DELETE Federal Tax ID Number 940890210 Number of Employees 0-200__________ s_ Address 4023 Cedar Springs P.ih/ Dallasstate TX Zip 7.5 2 lj TV-.'CC 20A (Rav. 10/93) Pagsm_ of 10 TEXAS WORKERS' COMPENSATION COMM'SSfON ChecKone: D Correction COR RE CTION/REVI SI ON/EN DORSEMENTTO Revision 0 Endorsement fr-Effective Date of Channe The current policy is hereby amended (State only what is being amended:-) Adding Locations and Amending Address of Insured. 03/01/2000 Name of Insurance Carrier: Pacific Employers Insurance Co. Name of Primary Insured: Cnevron Corporation 77 Address of Primary Insured: 6001 Bollinger Canvon Road Building E - 2rul Floor San Ramon, CA 94583 _ _ NCCI Number 10677 FEIN Number 940890210 Policy Number C42835584 Effective Date of Policy (mm-dd-yy) 03/01/2000 End Date of Policy (mm-dd-yy)03/01/2001 Date Carrier Notified Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check one: [xJ-ftOD DELETE .03/01/2000 Effective Date _________ , 940890210 Federal Tax ID Number Number of Employees, Name __________----------------Address 3306 Grand Avenue City. Dallas State JZ_____ Zip __L521Q_ Check one: GO ADD Effective Date 03/01/20007 DELETE Federal Tax ID Number 940890210 -- Number of Employees 0-200__________ _ Name Address 8210 S. Lan^^ter, ______ --7^--\ City. Dallas .4?teTXr7Q-r7ip 75241- Check one: B ADD ^Effective Date 03/m /?oott DELETE Federal Tax ID Number 940890210 Number of Employees 0-200_________ _= Name___________ :______________ Address4467 Simpson Stuart City DallasState 12_______________ Zip 75239 TWCC 2CA (Rev. 10/93) Page 8 of 10 TEXAS WORKERS' COMPENSATION COMMlSSiOf Check on8: Correction correction/revision/endorsement to existing policy Revision (3 Endorsement 03/01/2000 Effective Date of Change-------------------------- The current policy is hereby amended {State only what is being amended:-) Adding Locations and Amending Address of Insured. Name of Insurance Carrier: Pacific Employers Insurance Co. Name of Primary Insure# Chevron Corporation Address of Primary Insured: 6001 Bollinger Canyon Road Building E - 2nd Floor San Ramon, CA 94583 NCCI Number ~ 10677 FEIN Number 940890210 Policy Number c .2835584 Effective Date of Policy'___ End Date of Policy , i; (mm-dd-yy) 03/01/2000 (mm-dd-yy) 03/01/2001 Date Carrier Notified L nployer to Cancel (mm-dd-yy) Effective Date of Cane nation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check one: Q ADL Effective Date 03/01/2000 DELETE 940890210 Federal Tax ID Number______ Number of Employees 0-200 Name__________________ Address 600 IH 30 Check one: AD0 Effective Date 03/01/2000 DELETE Federal Tax ID Number 940890210 Number of Employees 0~2Q__________ Check one: ADD Effective Date 03/01/2000 DELETE Federal Tax ID Number 940890210 Number of Employees 0-200__________ Name___________________ Address 3300 Coit Dr. City PI ann State_JEX_____________ Zip .75023 TVvCr 20A (Rev 10/93) Page 9 of 10 TRXAS WORKERS' COMPENSATION COMMISSION Check one: Correction COR RECTiON/FtEVrbrUN/1= N UUH Revision 0 Endorsement fr-Fffective Date of Channe The current policy is hereby amended (State on]y what is being amended:-) Adding Locations and Amending Address of Insured. 03/01/2000 Name of Insurance Carrier: Pacific Employers Insurance Co. Name of Primary Inst., ed: Chevron Corporation Address of Primary Insured: 6001 Bollinge Canyon Road Building E - . nd Floor San Ramon, CA 94583 ^ -- NCCI Number tnfi7.7 FEIN Number 940890210 Policy Number 1 C42835584 -- Effective Date of Policy (mm-dd-yy) 03/01/2000 End Date of Policy (mm-dd-yy) 03 /01/2001 Date Carrier Notified Employer to Cancel (mm-dd-yy) Effective Date of Cancellation Date of Reinstatement (mm-dd-yy) (mm-dd-yy) LOCATIONS Check-one: (jj ADD Effective Date 03/01/2000" DELETE 940890210 .ZL Federal Tax ID Number Number of Employees 0-200 Name----------------------------------------Address 2198 E. Arapaho Rd. City Richardson-----State J2-------- Zip ,,,,ZflSl Check one: O At3D Effective Date DELETE Federal Tax ID Number______ Number of Employees_______ Check one: CH Effective Date DELETE Federal Tax ID Number______ Number of Employees_______ TWCC 20A (Rev. 10/93) Name _ Address City Page 10 of 10 StateZip TEXAS WORKERS' COMPENSATION COMMISSION 4000 South XH-3S Soutbliald Building- Austin, Texas 78704 DO' 0 ^0*4 OlO INSURANCE CARRIER NOTICE OF COVERAGE/CANCELLATION/NON-RENEWAL OF COVERAGE Insurance Carrier Information Empioyer/lnsured Information 1. Insurance Carrier Name Pacific Employers Insurance :Co. 7. Primary Employar/lnswed Name Chevron Corporation 2. Federal Tax ID No. (FEIN) 95-1077060 4. TWCC Carrier MBI No. 3. NCCINo. 10677 5. Policy Type 1E3 Standard d Divided Risk 3. Primary Empioyer/lnsured Business Mailing Address 6001 Bollinger Canyon Road, E1208B San Ramon, CA?45830 6. Type of Transaction (ehac one only) 0 Naw Policy Carrier 10 day Cane llarion/Non Renewal Q Carrier 30 day Cancellation/Non Renewal 8. No. of Locations and/or entities covered. (Exclude Primary Insured) 10. Federal Tax ID No. 94-0890210 0 Correction/Revision/Endorsement (attach TWCC-20A) 53 Renewal 0 Reinstatement 11. Employer's Workers' Comp Class Code 12. Estimated No. of Employees 0 Voluntary Backdated Effective Date of Policy 8810, 8832, 9015 1165, 1321,1463 6,134 4459, 4740, 7421 , 7515, 8006, 8350, 8742 , 8803 POLICY INFORMATION * .43.-Policy No. C42835584 14. Effective Dates of Policy: (mm-dd-yy) FROM 03/01/2000 TO 03/01/2001 16. Date Carrier Notified Employer of Cancellation: (mm-dd-yy) IS. Effective Date of Caneallatten/Reinstatemant: lmm-dd-yy) 17. Empioyer/lnsured DBA Name DIVIDED RISK INFORMATION LC-14198 CARRIER'S COPY Chevron Corporation 94-0890210 C4231805A Pleas Type Check one: B *0 DELETE LOCATIONS OF EMPLOYERS' BUSINESSES) TWCC5 TWCC20 EffectsDate Q3/oim" Name Address Chevron U.S.A. Products Cq. 7734 John Carroll Federal Tax ID Number____ . _ l---------- / Number of Employees. 65 City. Abilene State. TX Zip 79605 Check one: fxl ADD Effective Date. 03/01/1999 DELETE Federal Tax ID Number. 94-1529160 Number of Employees. -61 Check one: GO AD5 Effective Date---------0--3--/-0--1- /1999 n DELETE Federal Tax ID Number______ 25-0527925 Number of Employees. 36 Name Chevron Pipe Line Co. Address 602 E. Hardison Lane u" City_ Abilene State TX Zip 796_Q2_ Name. Address Chevron U.S.A. Production Co. HWY 361 East Cftv Arkansas Pass State TX Zip 78336 Check one: "- H3 ADD Effective Date..... 03^1 n DELETE ~ Federal Tax ID Number____ 94-0361642 Number of Employees. 36 Check one: GD ADO Effective Date DELETE 03/01/1999 Federal Tax ID Number__ 25-0524925 Number of Employees. 36 Name Address Plexco Inc. 5840 Interstate 20. Ste. #170 riity Arlington State. TX Zip 76017 Name Chevron Public Affairs Address 1005 Congress Ave. Suite 695 OBy Austin State TX Zip _..Z2-Q1.. Check one: GO ADD Effective Date _ DELETE 03/01/1999 Federal Tax ID Number 25-0524925 Number of Employees. 36 ______ Name__ Chevron U.S.A. Products Address. 1023 Springdale Rj City Austin S@e g *1 Zip 78721 TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Page _i_ of .66 ,SWORKERS' COMPENSATION COMMISSO Pleas Type LOCATIONS OF EMPLOYERS' BUSINESS(ES) TWCC 5 TWCC 20 Check one: 0 ADD Effective Date_______0_ 3_/_0__1/1999 Q DELETE Mama Chevron Chemical Co. Address 9500 1-10 East, Exit 796 Federal Tax ID Number---------- 94-0 36164 2_ Number of Employees. 36 City. Baytown. State Zip 2,7.121- Check one: 0 add Effective Date DELETE 03/01/1999 Federal Tax ID Number_______ 94-15291^0^ Number of Employees____ _________ 36 x. Name Chevron Pipe Line Co. Address 9405 W. Port Arthur Rd. City Beaumont State TX Tip 77705 Check one: - 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 25-0524925 Number of Employees______________ ------------------- Name Chevron U.S.A. Products Co. Address 9406 W. Port Arthur Rd. City Beaumont State TX Zip 77705 Qhack one: [B ADD EffectiveDate______ 03/01/199.9 DELETE __ Federal Tax ID Number_______25-05 ^925 Number of Employees36 ___________________________ Name Warren Petroleum Company Artrireaa Hwy. 380 WestX^7-- nay Bridgeport State_E2L__ Zip 76026 Check one: 0 ADD fc.IData 03/01/1991 Q DELETE - Federal Tax ID Number________ 94-1529160 Number of Employees______________ 50--------------- Name Chevron Pine Line Co. Address Hwy 155 & Sabine River __________ 2 Miles S. of Big Sandy 1. City Big Sandy State TX _ zip .7175.5 Check one: add Effective Date 03/01/1999 DELETE _ Federal Tax ID Number25-0524925 Number of Employees_______________ 36 TWCC 205 (Rev. 10/93) CK*1F45a (Ed. 12/93) paQe 2. Pleas Typo LOCATIONS OF EMPLOYERS' BUSINESSES) TWCC5 TWCC20 Check one: Name Chevron Pipe Line Co. & CITC A0 ^ab*"*.!**. 03/01/1999 Q DELETE -- Federal Tax ID Number 94-152916D----------- Address Extension of Bavlor St. __________Morgan Ranch_____________ ZZ Number of Employees--------------------------------------- -- filty Big Springs Stefa TX Zip 79720 Check one: ADD Effective Oate. 03/01/1999 DELETE Federal Tax ID Numhar 25-0524925 Number of Emolovees 56 " Mama Chevron U.S.A. Products Co. St. AHriraaa Hwy. 83 South and Cedar l/ r.ih/ Canadian State TX Zlo 79014 Check one: Q ADD EffectiveDate. DELETE 01/01/1999 Federal Tax ID Number 94-1=29160 Number of Employees 36 " Mama ^Warren Petroleum Company Address 3 MiZ'S-S'^of'-'Canadian On Hwys./60 & 83"''\ y ... Ctty Canadian State TX A sA' yr' Check one: 3 ADD Effective Date . DELETE 03/01/1999 Federal Tax ID Number 94-1529160 Number of Emolov* ees 36 ~ Check one: Q ADD Effective Date DELETE 03/01/1999 Fodnral Tav ID Number 94-0361642 Number of Employees 36 z Name Chevron Pioe Line Co. y___ uZ r.ttv# Hermleigh State TX----- Zip 79526--3J Name Chevron Chemical Co. Address 1515 S. Sheldon Rd. / l/ filly Channelview State__ 12-- np 7753CL CK-1F45a (Ed. 12/93) Please Type ______________________________________ ____ Mz.llgMJL- LOCATIONS OF EMPLOYERS' BUSINESS(ES) TWCC5 TWCC20 Check one: Name Warren Petroleum Company AD0 Effective Oate Q DELETE 03/01/1WC Address 13 Hi. S. of 1-20 On Federal Tax ID Number25-05J?4J?21L---------- FM 1053 Number of Employees. 36 City Crane State TX.. zip 79731 Check one: Q ADD Effective Date DELETE 03/01/1999 Federal Tax ID Number 94-152916CT Number of Employees 36 Check one: [xj ADD Effective Date DELETE 03/01/1999 Federal Tax ID Number 25-0524925 Number of EmDlovees 36 1 Name Chevron Pipe Line Co. Address P.0. Box 698 Citv Crane State TX 23d 79731 Name _ Chevron U.S.<k. Production Co Address 1/ Cftv Crane State TX____ ZId 79731 Check one: ADD Effective Date* DELETE Federal Tax ID Number Number of Emolovees 03/01/1999 25-0524925 361 Name Chevron U.S.,A.. Products Co. Address 4099 McEwen, Ste. If324 Cltv Pallas_______ Qtato TX Tin 75244-43: Check one: 0 AD0 Effective Date DELETE 03/01/1999 Federal Tax ID Number 25-0524925 Number of Employees . 36 - Name Chevron U.S. a. Products Co. AHdrA<M 7028 Judl Street- ,/ City .Dallas_______ State _J3____ Z4> 75252 Check one: 0 ADD Effective Date_______0__3_/_0_1/1999 DELETE Federal Tax ID Number_______94-036.1642 Number of Employees. 36 Name Chevron U.S.A. 6 Chevron P1^\ine C Address 4 Ml. E. City of Dawsog^^P^ -Hwy,_31. .. City. Dawson 766390, TWCC 205 (Rev. 10/83) CK-1F45a (Ed. 12/93) Page A_ of I ChV-gQH Corporation Please Type Check one: LOCATIONS OF EMPLOYERS' BUSINESS(ES) TWCC 5 TWCC 20 Warren Petroleum Company 0 A^D Effective Date 03/01/1999 DELETE Federal Tax ID Number ______ 25-0524925 Address 5 Mi. S. of Como on FM2948 Number of Employees. 36 City. Como State_TX__ zip 75431 Check one: ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 25-0524925 V Number of Emolovses 36 Mama Chevron Research & Technoloev Co. Adrfraas 1 Fluor Daniel Drive - RM. D5-62 \S Cltv Suearland State TX Tin 77487 Check one; El ADD Effective Date__________0_3_/_01/1999 DELETE Federal Tax ID Number_______25-0524925 Number of Employees. 36 Name Chevron U.S.A. Production Co. Address 104 West 6th Ctty Sundown State TX Zip _Z9 3,7.2- Check one: [xJ'ADD Effective Date_________0_3__/01/1999 DELETE Federal Tax ID Number 25-0524925 Number of Employees. 36 Nome Chevron U.S.A. Production Co. Adriraaa 4333 Oilfield Rd.-------------------- nify Thompson State-12-------Zip _7-ZML Check one: 0 ADD Effective Date _________0__3_/_01/1999 DELETE Federal Tax ID Number________25-0524925 Number of Employees. 36 Check one: 0 ADD Effective Date_________0_3__/0_1/1999 DELETE Federal Tax ID Number_______ 94-0361642 Number of Employees. 36 Name Chevron U.S.A. Products Co. Address 614 Hampton Hill Dr._________ L/ Ctty. Tvler grata TX Tip 75703. None Plexco. Inc. Address 1601 W. 287 Bv-Pass TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Pleasa Type Check one: ADD 1 I delftf LOCATIONS OF EMPLOYERS' BUSINESSES) QTWCC 5 Q TWCC 20 - Name Chevron PiDe Line Co. Effective Date 03/01/1999 Addrasa 2701 FH 1189 Federal Tax ID Number 94-1529160 Number of Emnlnynes 36 Cy Wesrherford-------- State. -- Zip. 760R7 Check one: ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0361642- Number of Fmnfnyees 36 N*ma Plexco Inc. Address '.09 H' llton (-ircie / 1/ CitV Weacherf'rd State TV -Zip -76118,6 - Check one: DO ADD effective Oate----------- 03/01/1999 Q DELETE Federal Tax ID Number25-0yi925s^------- Number of Employees35 ^________ Name____CMv on 175. A. Production Co. /' Address V Mlles North of Westbrook Ctv. Rd. 220 Cttv Westbrook.State TX zip 79565 Check one: (3* .-Bfac.TM, Data 03/01/1999 "DELETE Federal Tax ID Number 25-0524925.. Number of Employees ____________36 Name Chevron U.S.A. Production Co. Address " Mt. Ea3t of Coahoma on I 20 t/ (City CoahomaState--IS------ Zip .-7.2511------ Check one: ADD effective Date________0_3__/0__1_71999 Q DELETE Federal Tax ID Number_______ 25-0524925^ Number of Employees. 36 Name Chevron U.S.A. Production Co. Address 100`N O'Brien St. Cfty aicke te state _J3___ Zip ,7.25.1 L Check one: CE1 ADD Effective Oate________0_3_/_0_1/1999 Q DELETE Federal Tax ID Number_______ 25^0524925 Name Warren Petroleum Company AddrM 3 75 Miles North of Wtcki Ls 12J Number of Employees. 36 Cltv Wlckett TWCC 205 (Rev. 10/93) Psoa_6- of 66 NmwatxEn^^ff^dffia iBtCNCCWOSSOf CK-1F453 (Ed. 12/93) Please Type LOCATIONS OF EMPLOYERS' BUSINESS(ES) TWCC5 TWCC 20 Check one: Name Chevron Pipe Line Co, GO ADD Effective Date Q DELETE 03/01/1999 Address 2 Ml. N. of Wink, off Airport-.Rd Federal Tax ID Number __ 94-1529160 Number of Employees. 36 City. Wink State _TX_ Tip 79789 Check one: HIADD Effective Date DELETE 03/01/1999 Federal Tax ID Number______ 94-1529160 :_T Number of Emplc yees---------------------lh------- ----- Name Chevron PiDe Line Co. Address. 1400 Woodloch Forest Dr. ... / Cltv The Woodlands State TX ZJd 77380 Check one: ___ (3 ADD Effective Date 03/01/1999 Q DELETE Federal Tax ID Number______94-1529'*-iL--- Number of Employees_________ 36 ~____ Name _ Chevron Pine Line Co. Address. 3 , Mi,,. .on. FM,, 21__ City Worthamgfatp TX 23p 76693 Check one: [2 ADD Effective Hate" 03/01/1999 Q DELETE ^ Federal Tax ID Number 94-1529160-_____ Number of Employees_____________ 36-- -- Name Chevron Pipe Line Co. Address 10126 Hwv. 146 N. r;y Mnnr Bslvien____ State>-X2------ Zip 77.580, Check one: ADD Effective Date 03/01/1999 Q DELETE Federal Tax tD Number_______25-0524925 _ _ Number of Employees__________ .. 36. -------- Name Warren Petroleum Company Address 10119 Hwy, 146 N._________ ______ City ______State -------- Zip .-77..58E Check one: g ADO Effective Date_____0__3_/_0_T__71999 DELETE - Federal Tax ID Number_______ 25-0524925 Number of Employees. 36. Name Warren Petroleum Company Address 10319 Hwv. 146 City Mont Belvieu TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Page _Z_ of ,66. CQMMtS Please Type Check one: [3 AD DELETE LOCATI--O----N-=--S-----O----F-----E-- MPLOII YHSEgggR--S* busines-sr ce^s)J, TWCC 5 TWCC 20 Name Chevron Pipe Line Co. Effective Date______03/01/1999 Addresa 12426 Interstate 10 Federal Tax ID Number94-1529160 ------------------------------------------------------------------------- Number of Employees36____________________________ nay Mt. Belvieu----------State_I2-------- Zip --ZZ59Q Check one: S ADD Effective Date______03/01/1999 DELETE Federal Tax ID Number____________ 94-0361642_ Number of Employees-------------------------- ------------- Check one: H ADD t-EffactlvaDafa 03701/1999 DELETE Federal Tax ID Number___________ 94-15361642 Number of Employees_________________36 Name Chevron Companies______________ Address 15 Smith Rd. Claydesta Plaza Cltv MidlandState TX Zip 79705 Name Chevron U.S.A. Products Co. Address 4200 North FM 1788___________ City MidlandState TX Zip 79707 Check one: S ADD EffectiveDate 03/0L/1999 Q DELETE Federal Tax ID Number____________ 94-0361642 _ Number of Employees_______________ ,, Ji______ Name Chevron_U. S.A, Products Co.,. Aridmaa 1100 N. County Rd. 1160___ r.lty MidlandState-IS-- Zip 7 9JO ,1 Check one: El ADD Effective Date 01/01/1999 Q DELETE _ Federal Tax ID Number____________ 94-1529160 Number of Employees__________________ 36 Check one: -- Name Chevron Pipe Line Co. Address 3400 E. Highway 80\S_ nity MidlandState TX ... . Zip 797C Name Chevron Pine Line Co.^ CK-1F45a (Ed. 12/93) Please Type Check one: 0 ADD Effective Date DELETE Federal Tax ID Number----------- Number of Employees TWCC 5 1)3/01/1999 9550361642 TWCC 20 Name______ Chevron Pipe Line Co & Chevron I Technology/Co. Address. 911 W. 2nd Street 2 36 nHy OdessaState _J2L_ Zip 79763 Check one: SADD Effective Date *>,01/1999 DELETE - Federal Tax ID Number______________ 94-0361642 Number of Employees------------------------ r 3..6---------- Check one: 0 A00 Effective Date DELETE Federal Tax ID Mi imhor Number of Emolovees _ 03/01/1999 _ 75=0524975 36 Name______ Chevron Cheinical Co. Address FM 1006________________' iZ7 / Pity OrangeState TX zip 776 30 Name Address Chevron U.S.A. Products Co. End of West 7th St. . X ... t/ Citv Port Arthur state TX 71a 77641 Check one: Gp ADD Effective Date DELETE Federal Tax ID Number______ Number of Employees 03/01/1999 95-L 5 29160 36 Name______ Chevron Pipe Line Co. _____ Address Country Club Road_____ \ / f.Ity Ranger State----------------------IX--- Zip------ISxkl,.Q Check one: 0 ABD EffectivaDateJ3/01/L999 Q DELETE _ Federal Tax ID Number94-L529160_ Number of Employees^--16--------- NameChevron Pipe Line Co. Address 3 Mi. S. of 1-20 on Duncan Hastings Rd.\ / City Rosr.oeState TX 23p 7934 CK-1F45a (Ed. 12/93) Please Type LOCATIONS OF EMPLOYERS' BUSINESSES)' TWCC5 twcc2o Check one: Name Chevron U.S.A. Products Co.____ 0 ADD Effective Date______03/01/1999 DELETE Address 4851 Emil Rd. \_y/' Federal Tax ID Number25-0524925_________________ ____________--------------------------------------------------------- Number of Employees2j>__________ City San Antonio State TX Zip 78219 Check one: HI ADD EffactivaDate DELETE OWIIM -Z Federal Tax ID Number____________25-0524925 Number of Employees_________________ M._______ Check one: H ADD Effective Date OW/ini DELETE Federal Tax ID Number____________25-0524925 Number of Employees_________________ 36______ Name Chevron U.S.A. Production^, Address Rt. 3 Box 84_________________ / LX City Sherman State TX Zip 75090 Name Warren Petroleum .Company--------------Address Rt. 3 Box 85--------------------------J----- -L Clty ShermanState TX Zip 75090 Check one: -E Effective Date Q DELETE Federal Tax ID Number Number of Employees 03/01/1999 94-1529160 36 Name Chevron Pioe Line Co. One Mile North of Hiehwav 105 on Hwv. 326 . V City Sour Lake State TX Zip 77659 Check one: ADD Effective Date DELETE Federal Tax ID Nitmhor Number of Employees - 03/01/1999 94-1529160 36 Mama Chevron PiDe Line Co. Addmss 7000 S.H. 208 North -r-l______ V/ City Snvder State TX -- Tip 79549 Check one: 0 ADD Effective Date DELETE Federal Tax ID Number_______ Number of Employees_______ TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) 03/01/1999 94-1529160 26 Page .10 of Please Type LOCATIONS OF EMPLOYERS' BUSiNES8(Es)a TWCC 5 TWCC 20 Check one: Name Chevron U.S.A. Products' S ADD Effective Date Q DELETE 03/01/1999 Address Rt. 3 Box 414 Federal Tax ID Number---------- 25-0524925 Number of Employees. J1L ctty Eastland State TX zip 76448 Check one: ADD Effective Date.. __ 03/01/19L DELETE Federal Tax ID Number--------------------94-^329160 - Number of Employees. .36 Check one: Q ADD Effective Date DELETE Federal Tax ID Numher Number of Emoiovees 03/0 71999 Ji-Cf361642 16___ Name Address Chevron Pipe Line Co. 6325 Trowbridge Dr. City El Paso State TX Zip 79905 Name Address Chevron U.S.A. Products Co. & CITC 6501 Trowbridge Dr. Citv El Paso State TX Zi 79905 Check one: GO ADD Effective Date_______ 03/01/1999 Q DELETE "-- ^ Federal Tax ID Number__ __________ 25^0524925 Number of Employees. 36 Name Address Chevron U.S.A. Products Co. 6550 Gateway Blvd. East 1 z. City. El Paso State__ TX___Zip 7 7.905. Check one: - HI ADD Effective Date DELETE 03/01/1999 Federal Tax ID Number .. .84^-0618607_ Number of Employees. 36 Check one: ADD Effective Date DELETE Federal Tax ID Number----------- Number of Employees. 03/01/1999 94-1529160 36 NameAmerican Personnel Services Inc.-- Address 7500 Viscount Blvd., Ste. ffC-40 City El Paso State TX Zip _ 79925 -X Name Chevron Pipe Line Co Address. 3 Mi. E. of Wort CHy Wortham State ^ . __7 6 69 3 TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Page _LL of _6j> TEXAS ^SpKERSlXiMPENSATON COMMISS Please Type Check one: LOCATIONS OF EMPLOYERS* BUSINess<esT" Q TWCC 5 O TWCC 20 Name Chevron Chemical Co.----------------------- S ADD Effective Data 03/01/1999____ AWHraCQ 15710 JFK Blvd. Ste. 400 \/ DELETE Federal Tax ID Number94-0161642 "" -------------------------- ------ ---------------------------------------- Number of Employees.16_________ City Houston,-------------State --IX------ Zip --Z2.Q.12. Check one: 0 ADD Effective Date 03/0T/1999 DELETE Federal Tax ID Number____________ 94-0361.642 ., Number of Employees----------- ___________ 26_____ Check one: 03 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number____________ 25-0524925 Number of Employees___________________26 Name_____ Chevron Chemical Co. Address 3000 Post Oak Blvd. Pity HoustonState TX Zip 77056 NameChevron Petroleum Technology Co. Address 2202 Oil Center Ct._________ l7 City HoustonState TX Zip 77073 Check one: 0 ADD Effective Date 03/01/1999 [^DELETE Federal Tax ID Number____________ 84-0618607 Number of Employees___________________ 2-------- Name American Personnel Services. Inc^ Address 7225 Langtry, Ste. 100 ---- -------------------------------------------------:------------------ w z qty Houston.------------- State--XX-- Zip. 77QMI Check one: ADD Effective Date DELETE PoHaral Tnv in Nit imhor Niimhor nf Emolovees -- 03/01/1999 25-Q524925 36 Name Address Chevron U.S.A. Products Co. / 7741 Cannon St. ^ nun Houston State TX ZJn 7721 Check one: 0 ADD Effective Date DELETE Number of Employees . TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) 03/01/1999 25-0524925 36 Mama Chevron U.S.A. Production^;-----AP\ L 8484 U. Mnnrne Rd . /JU.____\ Hobbv Airnort Hansraa: Sc*---:--------- ntv Houston PageJ2 of 66. ' coWMtsac Please Type LOCATIONS OF EMPLOYERS' BUSINI TWCC 5 TWCC 20 Check one: ADD Effective Date DELETE Federal Tax ID Number---------- 03/01/1999 94-0361642 Name Chevron Pipe Line Co. & Chevron Info. Technology Co. Address 909 Fannin 2 Houston Centar -V- Number of Employees. _2_ raty Houston State. TX zip 77010 Check one: S ADD ^Effectjve Date 03/01/1999 DELETE Federal Tax ID Number_____________ 84-Q&186Q7 Number of Employees------------------------------2JL-------- Name American Personnel Fervf res. Tnc. Address 3001 Gateway Dr., ste. mo V City IrvingState TX Zip 75063 Check one: H ADD Effective Date DELETE Federal Tax ID Number Number of Emoiovees 03/01/1999 25-0514925 36 Name American Overseas Petroleum Ltd. / V" Address 125 E. John Carnenter Fwv. Cltv Irvine State___IX__ Zto 75062-225 Check one: GLADD .-Effective Data..... Oi/n/lW DELETE Federal Tax ID Number______________ 25-0524925 Number of Employees;36 Name _ Address Warren Petroleum Company HC03 Box 84, FM 2924 18 Mi. West of Karnes City fifty Karnes City grate TX zip 78118 Check one: Q A .Effective Date________03/<HA* DELETE Federal Tax ID Number 94-1529160 Number of EmDloveea 36 -- Name Address Chevron Pipe Line _Co_^ NW of Kermit, FM 874 Cltv Kermit state TX _ Zjd 79745 . Check one: [x] ADD Effective Date DELETE Federal Tax ID Number Number of Employees TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) 03/01/1999 Name AddrASS Chevron U.S.A. Production Co.-, fin 1 F r.amn Road S / s0>\ 25-0524925 ________ 36________ Cltv Kit crnre Page JJL of .66 StatedW %^W: sf tcxaSv/or;KERS- CO^NSATION COMfolSSOI \ \ Please Type Check one: Cl ADD DELETE LOCATIONS Of= EMPLOYERS-' TWCC 5 ' TWCC 20 Name Chevron Chemical Co. Effective Date 03/01/1999 Address 1862 Kingwood Dr. Federal Tax ID Number____________ 94-0351642 Number of Employees36 City KingwoodState TX Tip 77339. Check one: ----- 0 ADD Effective Date DELETE 03/01/1999 - Federal Tax ID Number2 5-0524 9 2 5_ Number of Employees--------------------------- 35---------- Name_____ Chevron U.S.A. Production Co. Address Hvr^. 21 East At Fickey Rd. -------------------------------- U-- City Kurten _State TX Zip 77862 Check one: 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number_____________ 25-0524925 Number of Employees25 Name' evron U.S.A. Production Address____3 Mi. East on Hwv. 359 a t/ City Laredo _________ State TX Zip 78043 Check one: -13 ADD Effective Data, 03/01/1999 DELETE Federal Tax ID Number_____________ 94-1529160 Number of Employees36 Name Address Chevron Pine Line Co. h-\ Mi. on Hwv. 356 No,rtb....o.,,QnaIaska---------------------------------------- City ,, -Lining,sio,nState--12----- Zip --77,351 Check one: 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number_____________ 94-0361642 Number of Employees 36 Name Chevron Pipe Line & Chevron Info. Cc Address 5 Mi. N. of Lufkin, 2 Mi. W. of Hvrs 59, At Corner of FM843/FM2251 'lA City LufkinState TX Zip 7591 Check one: [x] ADD Effective Date DELETE Federal Tax ID Number_______ Number of Employees_______ TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) 03/01/1999 25-0524925 Name Chevron U.S.A. Production^_d.3k------ Address Gulf Max West Profit, ------ & mffghnrp PI atfts'r&fsd .A S&IF' 4? a ntv Mnstan? Island StMeCrl^ _ ZilA A~. - Page _L5 of 66 \ TE&SWORKERS' COMPENSATION C0MMIS! Please Type Check one: ADD Effective Date DELETE Federal Tax ID Numhnr Number of Emoiovees TWCC5 03/01/1999 25-0524925 TWCC 20 Mima Warren Petroleum Company Address (Puckett Plant) Yt/. 36 Citv Ft. Stockton State TX Tin 79735 Check one: 0 add Effective Date DELETE Federal Ta* ID Numhnr Number of Emoiovees 03/01/1999 25-05/24925 _______ 36_________ Check one: 0 ADD Fffectiva Date DELETE Federal Tax ID Number Number of Emoiovees 03/01/1999 25-0524925 36 Name Address Chevron U.S.A. Products Co./ >/ 2525 Brennan Ave. Cltv Tort Worth state TX 2d 76106 Name , Address Warren Petroleum Company 417 Ridelea Bank Bide. / Citv Fort Worth State TX Tin 76116 Check one: 0 ADD Effective Date Q DELETE Federal Tax ID Number Number of Emoiovees 03/01/1999 25-0524925 Tfi Name AHHrast Chevron U.S.A. Production Co. HG 51 Bnv 1578 r/ riHi Gainsville state TX Tin 76240-93 Check one: 0 ADD ^Effective Date DELETE Fnrlnral Tax ID Numher Number of Emoiovees 03/01/1999 25-0524925 36 Mirnifl Address Chevron U.S.A. Production Co. 1300 E. Hwv. 158 T7^ r:ih/ Goldsmith State TX Tin 79741 CK-1F45a (Ed. 12/93) Please Type Check one: LOCATIONS OF eMPL.OYERWBIHIHnm) TWCCS TWCC20 Name Warren Petrole-urn Company. ADD Fff<reth/BData 03/0171999 DELETE -- Federal Tax ID Number_____________25-0524925_ Address 12801 American Petroleum Rd. :V Number of Employees---------------------------------------- y Galena Park State TX Zip 77547 Check one: ADD Effective Data DELETE Number of Employees Check one: ADD Effect, Date DELETE 03/01/1999 94-1529160 35=________ 03/01/1999 KJm* IHrlmM 12510 American Petroleum Rd. OBy Galena Park State TX Zip 77547 Name A/Mra** Chevron U.S.A. Products. .C.CL,---------- 3. 12523 American 1"troleum Rd. Numher of Employee* Check one: El ADD Effective Date Q.DELETE 36 03/01/19.99 City Galena Park State TX__ ZIP _ 77?4.7-- Name Chevron Research & Technology Co. -- L Mi. E. Number of EmDloyees 36 riy Hobson State__ 32-- Zip --13111-- Check one: 0 ADD EffectveDate______ 03/01/1999 DELETE Federal Tax ID Number 25-0524925 Number of Employees. 36 Name Chevron Information Technoloev-Co. Address 10200 Harwin_____________ rjty Houston "t State__IS__ Zip J7Q1L Check one: 0 ADO 03/01/1999 DELETE Federal Tax ID Number_____________ 25-0524925 Number of Employees. 36 Name. Address. riiAvrnn Servl r.ea. Ca ZZM 1Q4Q2 Harvin Dr QHy Houston Stat^^ap-;^>036 TWCC 205 (Rev. 10/93) Page_L of raCAS^WERS1 C0reH5iAT10N COMM1S9 CK-1F45a (Ed. 12/93) Please Type Check one: TWCC5 ADO Effective Date DELETE 03/01/1999 Federal Tax ID Number____________ 94-0361642 TWCC 20 Name Chevron Companies Address 10630 Fallstone Number of Employees______________________________ fifty Houstong^fo TX 7tp 77099 Check one: (3 ADD Effective Data DELETE Federal Tax ID Number _ Number of Emnfnynna 03/01/1999 94-036 L542 36 Check one: [jj] ADD Effective Data..... DELETE Federal Tax ID Number 03/01/1999 94-0351642 Number of EmDloveas 36 Name Address Chevron Companies lllll S. Wilcrest y \ .^ City Houston state TX Name Chevron Companies Zip 77099 / ,/ Address 1301 HcKinnev ... Hftv Houston State TX zto 77010 Check one: QJ ADD Effective Data pj-DELETE Federal Tax ID Number Number of Emoloyees 03/01A999 94-0351642 36 Name Chevron Companies / ArlHmM 1331 Lamar #4 Houston Center fifty Houston State__ IX----- Zip 77010 Check one: 13 Effective Date -----03/01/1999 Q DELETE Federal Tax ID Number_____________ 94-0361642 Number of Employees___________________ ----------- Name_____ Chevron Companies Address 2811 Haves Rd. fifty Houston gtate TX 71p 77082 Check one: G3 AD0 Effective Date DELETE Federal Tax ID Number_______ Number of Employees------------ 03/01/1999 94-0361642 36 Narrm Chevron Info. Technology Co. 6 Chevroi Rear Estacp Hgt. 1 Address 5959 Corporate DriVe 7 Xfi \ City Houston TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Page _LZ of 66 ^WC^S'^pNSAn0NC0MMISS Please Type Check one: LOCATIONS OF EMPL Q TWCC 5 TWCC 20 Chevron Pipe Line Co. (3 ADO Effective Data DELETE 03/01/1999 Address 1 Mi. E. of Hwv. 124 on Craigen Rd. Federal Tax ID Number 94-1529160 Number of Emolovaea _ 36 r>JKi Fannett State TX Zto 77705 Check one: ADD Effective Date Q DELETE Federal Tax ID Number Number of Employee?* 03/01/1999 94-0361642 36_ Mama Chevron U.S.A. Production Company Address Farm Road 2924 / nih/ Fashing State TX Tin 78020 Check one: 0 ADD Effective Date 0 DELETE Federal Tax ID Number Number of EmDtoveea 03/01/1999 25-0524925 36 Name Address Chevron U.S.A. Production Co. 1 Mi. N. of Ft. Stockton on Hwv/18 Cftv Fort Stockton state TX Tin 79735 Check one: 0 ADO Effective Data , 0 DELETE -- Federal Tax ID Number 03/01/1999 94-0890210 Number of Employees 36 Name 1/Mnm Caltex - Pallas_______ 125 E. John Carpenter Fwy. V nih/ Irvingstate TX Tin 75262-27 Check one: 0 ADD Effective Date 0 DELETE Federal Tax ID Number Number of EmDtoveea Check one: 0 ADO Effective Date Federal Tax 10 Number. Number of Employees _ TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) 03/01/1999 94-0890210 36 Name ,, Address PLEXCO. Inc. ,T 4438 Centerview Dr., Ste 307 rjh/ San Antonio State TX. Tin 78228 03/01/1999 94-0890210 Nama Address 2435 W. Miller Rd. ____ \. 36 r^y Garland .Page JLS of 66 r<3a> ^041 . v ^ yipemiONCOMMu P(aas8Type Check one: 0 ADD EffectiveDate. DELETE Federal Tax ID Number----------- Number of Employees. TWCC S 03/01/1999 TWCC 20 Name Warren Pet Co. Address Farms Road 2231 Plant #130 94-0890210 _1L nay Breckenridge State TX Zip 76024 Check one: GO AD^ Effective Date. DELETE Federal Tax ID Number----------- Number of Employees. 03/01/1999 94-0890210 36 Name Chevron Information Technology Address Rt. 6. Box 87________ V.------------ City Weatherford State TX Zip 76087 Check one: 0 ADD Effective Date Q DELETE Federal Tax ID Number_______ Number of Employees. 03/01 '1999 94-1529160 36 Name Chevron Pipeline Co,. Address Intersec, of Hws,.._L83 & 69- CltyEastland State TX Zip 76448, Check one: (3 ADD EffectiveDate. QJ3ELETE Federal Tax ID Number_______ Number of Employees. 03/01/1999 94-16008853 36 Name Address Chevron Overseas Petroleum Inc c/b Brown & Root 10020 Bellaire Blvd. City.Houston., State JDL -----.Zip, 77.D.7.2. Check one: 0 ADD EffectiveDate. DELETE Federal Tax ID Number_______ Number of Employees. 03/01/1999 94-0890210 36 Address 8300 S. Stemmons J_____ ___ nitv Hickory Creek Stale TX 7ip 76205 Check one: H ADD Effective Date 03/01/1999_ Q DELETE Federal Tax ID Number____________ 94-0890210 Number of Employees. 36 Klamo Address Chevron Corporation ISKI 4TQ0 NW Ram Houston__ -------------------------------------- ---------------------------- City. Houston TWCC 205 (Rev. 10/93) Page.19 of _66 C$$ENSAT1CN COMMISaa CK-1F45a (Ed. 12/93) Please Type AD Effective Date DELETE FflHftral TflY ID Ml imhur Number of Emnioveea TWCC S TWCC 20 03/01/1999 94-0890210 41 ArlHmas Cllv state 2ki Check one; Q ADD Effective Date Q DELETE Federal Tay IH Mi imhar Number of Emoiovees Check one: 0 ADD Effective Date DELETE FarlaralTay in Number Number of Emoiovees 03/01/1999 94-0890210 41 03/01/1999 94-0890210 41 Mofne Address Chevron Corooration Cltv State ZIo Marne Address Chevron Corooration Cttv State Zip Check one: Q1 ADD Effective Date Q DELETE FaHaral Tay in Ni imhar Number of Employees ............... 03/01/1999 94-0890210 41 N^o ArMraaa Chevron Corporation City State Zip-------------- Check one; (3 AD0 Effective Date DELETE Parlaral Tay in Ni imhar Number of Emoiovees Check one: GO ADD Effective Date DELETE Federal Tov in Mi imhar Number of Employees , .......... TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) 03/01/1999 94-0890210 42 03/01/1999 94-0890210 25 Name Addroaa Chevron Corporation Cltv State Zkt Name Chevron Stations, Inc. v 102 Central Expressway ------------------- ^1 G#y Alla" - Page 2Q of 66 ,workers' coareHSWKN commis <\- LOCATIONS or* CM*LUTEnO Please Type TWCC5 TWCC20 Check one: Name Chevron Stations, Inc. GO AD0 Effective Date DELETE 03/01/1999 Address. 3394 S. Watson Road Federal Tax ID Number---------- 94-0390210 Number of Employees. 25 City. Arlington State. TX 2p 76014 Check one: ADD Effective Date Q3/01/1999. Q DELETE Federal Tax ID Number________ 94-0890210------ Number of Employees. 25 Check one: 0 ADD EffectiveDate. 03/01/1999 Q DELETE Federal Tax ID Number_______ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Addrasa 1440 S. Bowen City. Arlington State. TX .Zip 76013 Name. Chevron Stations, Inc. 5503 W. Arkansas Lane City Arlington______ State Zip 76016 Check one: -- ap otectiw Date H0V01Z52! DELETE Federal Tax ID Number____ 94-0890210 Number of Employees. 25 Name. Address Chevron Stations, Inc. 4340 Little Road City. Arlington Stale. -* .-Zip ..26016.. Check one: m ADD Effective Date 03/01/1999_ DELETE Federal Tax ID Number_______ 94-0890210------ Number of Employees. 25 Check one: EH ADt3 Effective Date 03/01/1999 DELETE Federal Tax ID Number_______ 94-08902L0 Number of Employees. 25 Name Chevron Stations, Inc. Addrasa 1225 Bardin Road y filty Arlington State. TX 76018 Zip Name Address Chevron Stations, Inc 5400 Matlock City Arlington 76018 7WCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Page jLL of -- C0MRJN3ATICN COMMISSIC Please Typo LOCATIONS OP tMt-turcno *IRC<99\i TWCC 5 TWCC 20 Check one: 0 ^ Effective Date 03/01/1999, Q DELETE Federal Tax ID Number___ 94-0890210 Chevron Stations' Itic* Address 5711 Green Oaks Number of Employees. 25 ^ Arlington State. TX Zip 76016 Check one: [H ADD Effective Date____ 03/01/E999_ DELETE Federal Tax ID Number----- 94-08902TO Number of Employees. 25 Check one: ADD EffectiveDate____ 03/01/1999. DELETE Federal Tax ID Number. 94-0890210 Number of Employees 25 = Name Chevron Stations, Inc. Address 3550 *'ar West V City. Austin State TX Zip 78758 Name Che-\ ron Stations, Inc. Address 28 ^ Guadalupe Citv Austin state Tin 78705 Cbeck one: [xj ADD EffectiveDate. 03/0l7l999 Federal Tax ID Number. Number of Employees. 94-0890210 25 Name .. Chevron Stations, Inc. Address_ 3324 Northland Drive City. Austin State-- Zip 78731 Check one: E ADO a,***, Date___ 03/01/ljM. DELETE Federal Tax ID Number___ 94-0890210 Number of Employees. 25 Check one: ADD Effective Date. 03/01/1999 DELETE Federal Tax ID Number._______ 94-0890210 Number of Employees. 25 Name Address Chevron Stations, Inc. 1-950 William Cannon ' 7^^8745 TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Page. 22 ^ 66 WORhfeSF'COMreNSATION COMMIS Please Type Check one: LOCATIONS OF EMPLOYERS' E*u" TWCC 5 TWCC 20 Name Chevron Stations, Inc. OD*00 Effective Date 03/01/1799 DELETE Federal Tax ID Number _____ 94-0890210 Address 13466 Research Blvd Number of Employees. 25 City Austin. State TX 71p 78750 Check one: S ADD Effective Date 03/01/1799 DELETE Federal Toy in Number 94-08902101 Number of Emplo, ees 25 Name ___ Chevron Stations. Inc. - Address 4400 Manchaca City Austin State TX ZJd 78745 Check one: SADD Effective Date------ ?./? 1/1999--------- DELETE _ Federal Tax ID Number 94-0890210_________ Number of EmployeesH___________________________ mahm Chevron Stations, Inc.______ ______ 2909 West Anderson Lane ----------------------------------------------------------------------City AustinState TX Zip 78757 Check one: __ 0TADD Effective Date 03/01/1J99 DELETE Federal Tax ID Number________94-0890210 Number of Employees__________ ___________ Name _ Chevron Stations, Inc. Address 6903 Brodie Lane city Austin State. TX Zip 78745 Check one: 0 ADO Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees 25 Name _ Chevron Stations, Inc Address 13775 Research City AustinStateZip . S7ft*75-0- Check one: 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number_______ 94-0890210 Number of Employees. 25 Name Address TWCC 205 (Rev. 10/93) Page 23_ of Chevron Stations, Inc. ^503 Garth .7-7321 ,it.y WCRXE^^UPENSATICH C0MMIS5 CK*tF45a (Ed. 12/93) Please Type Check one: 0* LOCATIONS OF EMPLOYERS' BU8tNE(B) f~lTWCC5 Q TWCC20 Name Chevron Stations, Inc. Effective Date 5027 -V" DELETE Federal Tax ID Number _94:0890210 - Number of Employees__________ 2__5_________ nay BaytownState TX Zip 77520 Check one: 0 ADD Effective Date 03/01/1959 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees_______ 25 Check one: 0ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 - 25 __ Number of Employees_______________________ Check one: wEnr*A0n0n Effective Date --_0_3__/0__1_/1=99--9 pi DELETE Federal Tax ID Number 94-0890210 _ Number of Employees ________ 11----------- :-- Name Chevron Stations, Inc. Addraim 4115 East Lucas________ City BeaumontState IX Zip 77708 Name _ Address Chevron Stations, 195 North 1-10 City. Beaumont State. TX Zip. 77707 Check one: H Effective Date 03/01/1999 DELETE Federal Tax ID Number_______ 94-0890210 Number of Employees____________25 ... Check one: -- 0ADD Effective Date _23mOT99__ DELETE Federal Tax ID Number94-0890210 Number of Employees___________2_5 - Name Chevron Stations, Inc. Address. 1512 Brown Trail XyCf City. Bedford --:-- rf&gfe: aP, 1^21., TWCC 205 (Rev. 10/93) ry / Pafl -- of 66 TEW^WOBXEflS- COMPENSATION COMMISS CK-1F45a (Ed. 12/93) Please Type Check one: LOCATIONS OF EMPLOYERS' BUSINESSES) " TWCC5 TWCC20 Name Chevron Stations, Inc. 0 ADD Effective Date__ Q3/Q1/19-.9, n DELETE Federal Tax ID Num.ber_______9_4_-_0_8_9_0_2__1_0____ Addmsa 5020 Bellaire Number of Employees----------------2--5--------------- fifty BellalreState TX Tip Check one: -- m Effective Date 03/01/1g n delete Federal Tax ID Number 94-0890210 __ 2 * Number of Employees----------------- ------------ -- Name _ Address Chevron Stations, Inc. 8522 Hwy. 377 South City BenbrookState ^ Up 76126 Check one: ---- IU ADD EffectiveDate n delete Federal Tax ID Number 94-0890210 ___ Number of Employees___________2_5________ -- Name Chevron Stations, Inc. Address 1-3451 South Freeway City BurlesonState TX Zip__________ 76028 Check one: -- RtUn ADD ^Effective Da.te__'"_0__3_/_0_1_/_1_9__99_ n DELETE Federal Tax ID Number______ 94-0890210 Number of Employees__________^__________ Name____C__h_e_v_ro_n___S_t_a_t_io__n_s,L Inc. Address 1010 W. Frankford nay Carrollton State--22L-- Zip --Z5.QP.Z Check one: 0" fcEHretto.DM., 03/01/1999 DELETE _ Federal Tax ID Number______ 94-0890210 ^ Number of Employees___________2_5________ _ N.. ame_____C_h__e_v_ro__n__S_t__a_t--io-n--s--,---I-n--c--.Address 3702 Josey Lane________ fifty Carrollton state TX Zip 75006 CK-1F45a (Ed. 12/93) Please Type LOCATIONS OF EMPLOYERS* BUSINESSES) TWCCS TWCC20 Check one: jTJ ADD Effective Date 03/01/19:99 DELETE Federal Tax ID Number__ 94-0890210: Number of Employees. 25 Check one: (3 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number---------94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address. 1901 Beltline Road X City. Carrollton State. TX Zip. 75006 Check one: Hi ADD Effective Date 03/01/19-9 9 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Check one: PH Effective Date ..-Q3/01/1999 Q DELETE Federal Tax ID Number______ 94-089021C Number of Employees. 25 Chevron Stations. Inc. Address. 2230 Marsh Lane gfty Carrollton State TX Zip 75006 Name. Chevron Stations, Inc. 3907 Colleyville Blvd City. Colleyville State. TX Zip 76034 Check one: S3 ADO Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address. 309 N. Frazier Street City. Conroe State___ ____ Zip 77301 Check one: HI ADO Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address 1405 M Loon 336 West. City. Conroe TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Page of 3WORKERS' aMtENSATON COMMISSON Please Type Check one: TWCC 5 TWCC 20 Name Chevron Stations, Inc. PP AD Effective Date__ _________________ DELETE ArWro** 101 E. Beltline y Address----------------------------------------- \------- ---------- Federal Tax ID Number 94-0890210------------------------------------------------------------------------------------------------------ Number of Employees12 _________________________ Cy CoppellState TX Tip 75019 Check one: 3 A00 Effective Date _ 03/01/l_g DELETE Federal Tax ID Number 94-0890210 Number of Employees__________ 11______ _ Name _ Chevron Stations, Inc. Address 2123 Hwy. 90 Cftv CrosbyState TX Zip 77^32 Check one: _ [X} ADD ^Effective Data 03/01/1999 DELETE Federal Tax ID Number 94-0890210 _________ Number of Employees25 ________ Name Chevron Stations, Inc. 11005 Grant Road ----------------------------------------- cay CypressState TX zip 77429 Check one: _ EL4P >-EffacllvaDMB ~.03l0llli?9 DELETE ^ Federal Tax ID Number 94-0890210 Number of Employees__________ 25 Name _ Address Chevron Stations, Inc. 13755 Cypress N. Houston city CypressStateZip -11221 Check one: i*" .Effective Date 03/01/1999 DELETE ~ Federal Tax ID Number_______94-0890210 Number of Employees__________ ?_5_________ Name '"Clieevron Stations, Inc. Address Warehouse City. Dallas State TX Zip 75244 Check one: ADD Effective Date 03/01/1199 DELETE Federal Tax ID Number_______ 94-0890210 n5 -- Number of Employees__________ ___________ Name Chevron Stations, Inc. Address. 7651 Campbell Road r- z-' City. Dallas ^OT?^Ziptri7:-5248 TWCC 205 (Rev. 10/93) __ Page 22. of Jj6 TmsWORKERS'^bwreNSATlON COMMISSION CK-1F45a (Ed. 12/93) Please Typo CunheecKk uone;: 0 AAD0O DELETE locations of employers* businesses*) TWCC5 TWCC20 Name Chevron Stations, Inc_._ 03/01/1999 .............................. QA-nRon?!n i (Rev. 10/93) CK-1F45a (Ed. 12/93) Page 28 of 66 LOCATIONS OF EMPLOYERS' BUSINESSES) Please Type Check one: Q TWCC 5 Q TWCC 20 nL . Name .. JLdLXUUOf XUL El ADO Effective Date 03/01/19199 DELETE Federal Tax ID Number__ 94-0890210 Address 8235 S. Hampton Road JK Number of Employees. 25 f-tfh, Dallas State TX Tin 75237 Check one: d ADD Effective Date 03/01/1999 Q DELETE Federal Tax ID Number--------- 94-0890210 Number of Employees. 25 Chevron Stations, Inc. Name___ Address 2860 East Ledbetter City. Dallas State. TX Zip 75216 Check one: [xj ADD Effective Date 03/01/1599 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Chevron Stations. Inc. AiHHraan *023 Cedar Springs 7 City. Dallas State TX .... Zto 75219 Check one: PH ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees 25 NamA Address Chevron Stations, Inc. 3306 Grand Avenue ' \ -----_k_ Oh, Dallas State-. TX .... Zip. 75210 Check one: 00 AD0 O km Data 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address _ 2344 W. Ledbetter VA__________ on,# Dallas Stata TX..... Z?n 75211 Check one: OD ADO Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-089021QT Number of Employees. 25 _____ Name Chevron Stations, Inc. Address 5651 Lemon Avenue City. Dallas TrTT TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Page 29 of 66 WORKERS1 COMPENSATION COMMISSOf Please Typo LOCATIONS OF EMPLOYERS' BUSINESS(ES) TWCC 5 TWCC20 Check one: Name Chevron Stations. Inc. (3] ADO Effective Date 03/01A999 DELETE Federal Tax ID Number__ 94-0890210 Address 8210 S. Lancaster Number of Employees. 25 raw Dallas State TX 75241 Check one: ES*00 DELETE Federal Tax ID Numhar 03/01/1999 94-08902 10 Number of Employees______ 25 Name Chevron Stations, Inc. Address. 4467 Simpson Stuart \ Cltv Dallas State TX ZlD_ 75239 eck one: ADD Effective Date _0V01A999_ DELETE leral Tax ID Number 94-0890210 Tiber of Employees______ 25 jne: 3 Effective Data-- 03/01/1999 .ETE 94-0890210 Number of Emofovees 25 Name Che iron Stations. Inc. Address 795 3 Forest Lane < City Dallas State. TX .Zip. 75230 Name____C__he_v_ro_n__S__t_a_ti_o_n_s_,_ 18190 Dallas Pkwy. ntht Dallas State TX 7,n 75287 Check one: GO ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emoiovees 25 Name Chevron Stations, Inc. - Address 2358 Royal Lane 3< Cltv Dallas State TX 7In 75229 Check one: GO ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 - Number of Employees. 25 ______ Name Chevron Stations, Inc. AHrtraM 7233 W. Carpenter ----V" ----------- City. Dallas TWCC 205 (Rev. 10/93) Page.30 of 66 WORKEH^OUPENSATION COMMiSSO CK-1F45a (Ed. 12/93) Please Type LOCATIONS OF EMPLOYERS' BUSINESSES) TWCC 5 Q TWCC20 Check one: ------------ ---------. (3 ADO Effective Date. 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Address. 8817 Clark Road Number of Employees. 25 CKv Dallas State -x TX 7? 75249 Check one: Q" ^Effective Date 03/01A9W DELETE Federal Tax ID Number__ 94-0890210 Number of Employees. 25 Name _ Chevron Stations, Inc. Address 7107 S. RL Thornton Frwy. City Dallas State TX Zip 75232 Check one: Ixl add t ffective Date. 03/01/1999 DELETE 94-08902 LOl Number of Emnloveas 25 Name. Chevron Stations. Inc. Address. 3001 Kno:c Cftv Dallas state ^ Tin 75205 Check one: El ADD Effective Date ,, 03/01/1999 Federal Tax ID Number. 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. AAtreea 11801 Webb ChaPel City. Dallas state zip 75234 Check one: E ADD ( ffective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Address Chevron Stations, Inc. 18220 Midway Drive A_ CHv Dallas State TX Tin 75252 Check one: H ADD Effective Date - 03/01/1999 DELETE Federal Tax ID Number______ 94-089021Q_ Name Address Chevron Stations, Inc. 12516 Northwest Hwy. Number of Employees. 25 ______ City Dallas TWCC 205 (Rev. 10/93) Page .31. of 66 75228 H^------- 'A WORKERS' Cffl^SATON COMMISSIOi CK-1F45a (Ed. 12/93) Please Type Check one: LOCATIONS OF EMPLOYERS' BUSINE8S(ES) TWCC 5 TWCC 20 mti Chevron Stations. Inc. 0 ADD Effective Data 03/01/1999 DELETE Federal Tax ID Number 94-0890210 AHHnm 9455 Forest Lane Number of Emnlnverm 25 r^ Dallas State TX Zb 75243 Check one: 03 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emolovees 25 Neme Address Chevron Stations. Inc. 10002 Marsh Lane \/ Cltv Dallas State TX Zb 75229 Check one: 00 ADD Effective Hate 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees 25 Name _ Chevron Stations, Tnc. i/WroM 1607 Regal Row Cltv Dallas State TX Zlo _ 75247 Check one: El ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 9.4-0890210 _ Number of Emolovees 25 Name Arlrtimm Chevron Stations. Inc. 4150 N. Central Expressway cth/ Dallas State- TX -Zip- 75205 Check one: BO APD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Name Chevron Stations, Inc. Address _ 101 N. Hampton Number of EmployeesCity PesotaState__22L_ Zip _7 51.1.5 V Check one: Chevron Stations, Inc^ CK-1F45a (Ed. 12/93) Pfease Typo TWCC 5 Check one: S AD0 Effective Date 03/01/1959 DELETE Federal Tax ID Number__ 94-0890210 Number of Employees. 25 TWCC 20 Name Chevron Stations, Inc. Address. 703 South Main City. Duncanville State. TX Zip 75137 Check one: ADD Effective Date 03/01/1599 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name. Chevron Stations, Inc. Address. 1791 Lee Trevino @ Trawood City. El Paso State. TX Zip 79935 Check one: [X] ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210"" Number of Employees. 25 Check one: 0 ADD EffectiveDate. 03/01/1999 .DELETE Federal Tax ID Number _______ 94-0890210 Number of Employees. 25 Name. Chevron Stations. Inc. Address 4135 Mesa Waymore City. EL Paso State TX_7Io 79912 Name Chevron Stations, Inc. Address. 7812 Gateway East @ Gile City. El Paso State--Z-- Zip -2221L Check one: ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name. Address Chevron Stations, Inc. 6631 Montana @ Airways City. El Paso State TX Zip 79925 CK*1F45a (Ed. 12/93) LOCATIONS OF EMPLOYERS' BUaiRew*<ie*y Please Type Check one: TWCC5 TWCC20 Mama CheVTOTl Stations, Inc. DO ADD Effective Date 03/01/1999 AHHrooft 1421 R. V. Drive @ I-10 DELETE FAnerai Tay in Numner 94-0890210 ------ Ir------d-- Number of Employees 25 City E1 Paso State TX Zip. 79927 Check one: 3 ADD effective Date 03/01/1599 DELETE Federal Tax ID Number 94-0890210 Number of Employees 25 Chevron Stations, Inc. 7299 Alameda @ Coronado City El Paso State TX zip. 79907 Check one: (U ADD Effective Date -- 03/01/1959 DELETE Federal Tax ID Number 94-0890210 Number of Employees 25 Chevron Stations, Inc. 3431 Alameda @ Grama :A-V-- \, City E1 Paso State TX Zip. 79905 Check one: E] ADD Effective Date 03/01/1999 n delete Federal Tax ID Number -94-0890210 Number of Employees 25 Chevron Stations, Inc. 214 Val Verde At Paisano City E1. Paso StAtA. TX .Zip 79905 CK-1F45a (Ed. 12/93) Please Type Check one: LOCATIONS OF EMPLOYERS' BUSINESSES) TWCC 5 Q TWCC 20 Name onevron oLaLions, me* E*00 k-ElfectiuoDU. 03/0L/I999 DELETE Forioral Tav in Mi mhnr 94-0890210 -- Address 1895 George Dieter Number of EmnJoveea 25 CRv E1 Paso State TX Zb 79935 Check one: - jj ADD Effective Date 03/01/1999 DELETE Fedaral Tav ID Number 94-0890210 Number of Emolovees 25 Name Chevron Stations, Inc. i - Address 745 N. Zaragosa Citv E1 Paso State TX . Zip 79907 Check one: HADD Effective Date 03/01/1999 DELETE Fflriflml Tav ID Number 94-089021(1 Number of Emolovees 25 Check one: E3add Effective Date 03/01/1999 DELETE Fadaral Tav in Numher 924-0890210 Number of Emolovees 25 Name Chevron Stations, Inc. Address 9500 Dyer St. Citv El Paso State TX 23d . 79924 Chevron Stations, Inc. Name _ - Address 901 N. Resler X C,,itv E1 Paso TX 79912 State. .23d -- Check one: _l GO ADD Effective Date 03/01/1999 DELETE Federal Tav in Nnmher 94-0890210 Number of Employees, ____ 25 Name Chevron Stations, Inc. - Address 430 N. Yarborough City El Paso State TX .Zip __ 79.915-- Check one: _ GO ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 - Number of Employees. 25 _____ Chevron Stations, Inc. Arirlreae 221 N. Main City. Euless Adir------ g&p 76039- TWCC 205 (Rev. 10/93) Page 21 of TEX^<MK^S|J^PENSAT1CN COMMISSCN. CK-1F45a (Ed. 12/93) PtoaoTyp* Check one: "^STToNSOFEMPLOYERa1 twccs TWCC20 Mama Chevron Stations. Inc. 0 k.Eftacb.O. 03/01/1999 DELETE Federal Tav in Ni imhor 94-0890210 Addnaaft 1014 N. Industrial Blvd V" Number of Emoloveea 25 n*v Euless State TX 71n 76039 Check one: U ADD Effective Date 03/01/1999 DELETE Fflf1flP*l Tav ID Ml imhor 94-0890210 Number of Fmnlovoes 25 Name Addreee Chevron Stations, Inc. 6549 Wichita St. r>lh/ Forest Hill ctnta TX Zfa 76102 Check one: OD ADD Effective Date 03/01/1999 DELETE Federal Tav in Ni imhor 94-0890210 ^ Number of Emoloveea 25 NJapna /VfdrtMMI Chevron Stations, Inc. 6600 North Beach \ A CBv Fort Worth State TX Zto 76137 Check one: EfADD Effective Date 03/01/1999 DELETE Federal Tav in Numhnr 94-0890210 Niimhor of Emoloveea 25 hfama AHHraeo Chevron Stations, Inc. 5925 Overton Ridge Y ntHj Fort Worth Siam TX .ZIP- 76132 Check one: 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number_______94-0890210 Number of Employeestl__________________________ Mama Address Chevron Stations, Inc. 1400 Eastchase Pkwy. city Fort Worth_____ State _J2------ Zip Check one: Chevron Stations, Inc^ CK-1F45a (Ed. 12/93) PtasTyp cMHuoYBRi1 TWCC 5 Q TWCC20 Check one: Mama Chevron Stations. Inc. (T] ADD Effective Date 03/01/1999 DELETE 94-0890210 Atjflr0** 6433 McCart Avenue r Number of Employees 25 Ctv Fort Worth st-te TX Tin 76133 Check one: ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emnlovees 25 Name Chevron Stations, Inc. " Address, 4533 Belair Drive Cltv Fort Worth stala TX zto 76109 Check one: (x] ADD Effective Date 03/01/1599 DELETE Federal Tax ID Number 94-0890210 Number of Employees 25 Check one: 0ADD Effective Date. 03/01/1999 | | DELETE Federal Tax ID Number 94-0890210 Number of Employees 25 Name Chevron Stations, Inc. " AOflr0f!8, 1330 Woodhaven Blvd. \ Cltv Fort Worth State TX 7In 76117 Name Chevron Stations, Inc. - Address 6600 Meadowbrook Dr. t. ^ Hfh, Fort Worth state TX Tin 76112 Check one: EADD Effective Date 1 I npi ptp 03/01/1999 Federal Tax ID Number. 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. 700 E. Berry Address. ........ x -V \------------- City. Fort Worth State TX 71p 76110 CK-1F45a (Ed. 12/93) PtaassTypa TWCCS TWCC20 Check one: Name Chevron Stations. Inc. \ / A Effective Date 03/01/1999 DELETE Federal Tax ID Number__ 94-0890210 Address 3017 W 7tb Street Number of Employees. 25 Cty. Fort Worth State IX zip 76107 Check one: jj ADD Effective Date 03/01/1939 DELETE Federal Tex ID Number 94-0890210 . Number of Emoiovees 25 Name Chevron Stations, Inc. 2000 Sycamore School Road /^\ -- Address Cltv Fort Worth state TX Tin 76134 Check one: HI ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emoiovees 25 ' Check one: El ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number ~9-4r0890210 Number of Emoiovees 25 Check one: - 51 AD0 Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emoiovees ___ 25 Name Chevron Stations, Inc. - Address 5601 C rowley --av . nv Fort Worth State TX___ ZIP 76134 Name Chevron Stations, Inc. - Address 6350 Camp Bowie Blvd. Cltv___Fort Worth_____ State XX, -- ZIo --76116 N*ma Chevron Stations, Inc. - Address 9401 White Settlement Road x ' Rfer Fort Worth State TX tv, 76108 Check one: ADD Effective Date 03/01/1999 - Federal Tax ID Number. 94-089021Q Number of Employees. 25 ______ Name Chevron Stations, Inc. Address. 101 West Parkwood C^y Friendswood v- ax/.77456 T" TWCC 205 (Rev. 10/93) Page 38 of 66 C0MMB9C CK-1F45a (Ed. 12/93) Please Type LOCATIONS Of2 EMPLOYERS' BUHNES8(ES; 0TWCC5 TWCC20 Check one: ------ S AD0 Effective Date 03/01/1999 DELETE Federai Tax ID Number__ 94-0890210 Address. 6102 Steward Avenue S. Number of Employees. 25 Galveston State TX _ Zlo ______ 77550 Check one: ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number___ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address 3080 S. Jupiter City. Garland State rc Zip 75041 Check one: [X] ADD Effi jtive Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name. Chevron Stations, Inc. Address 780 E. Centerville Xy V CRy_ Garland State TX ZIP 75042 Check one: ITjApD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address 2434 Beltline \, .A______ nitv Garland state TX Tin 75042 Check one: E ADD Hli CUV. Date 03/01/19X9 DELETE Federal Tax ID Number_______94-0890210 Name _ Chevron Stations, Inc. Address. 3310 Lavon Road CK-1F45a (Ed. 12/93) LOCATIONS OF EMPLOYER) TWCC5 Q TWCC20 Check one: Name Chevron Stations, Inc. SAD0 Effective Date 03/01/1^99 DELETE Federal Tax ID Number__ 94-08902101 Address. 7235 N. George Bush Frwy. Number of Employees. 25 City. Garland State_2L__ Zip 75044 Check one: -- 3 0 Effective Date 03/01/1^99 DELETE Federal Tax ID Number__ 94-0890210 Number of Employees__ 25 Name. Chevron Stations, Inc. Address. 3915 S. Great Southwest Pkwy. Z. Oltv Grand Prairie statQ Ti X ZIP 75051 Check one: S ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210' Number of Employees 25 HLADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Empiovees 25 Name__ Chevron Stations, Inc. Address. 301 Marshall raty Grand Prairie TX Zip 75051 Chevron Stations, Inc. 725 West Hwy. 303 X. nm, Grand Prairie ^ ZiD 75051 Check one: -- GD ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210-- Number of Employees ........... 25 Name Chevron Stations, Inc. - Address 101 E. Hwy. 114 __i________ -------\ rah/ Grapevine State _TX____Zip 76051 Check one: 0 ADD Effective Date 03/01/1799 DELETE Federal Tax ID Number 94-0890210 Number of Employees. 25 ______ NlamB Chevron Stations, Inc. 2041 W. NW Hwy. Cltv Grapevine TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Pafleit2 of .66 >0* v-v o' Please Type WBHi _______ LOCATIONS OF EMPLOYERS' B TWCC 5 TWCC 20 Name Chevron Stations, Inc. 0ADO Effective Date 03/01/1999 n delete Federal Tax ID Niimhar 97 4--0890210 5101 Hwy. 121-A Number of Emoioveea 25 ran, Haltom City TX Tin 76117 Check one: ADD Effective Date 03/01/1999 Federal Tax ID Number. Number of Employees- 94-0890210 25 Name Chevron Stations, Inc. Address 8300 S. Stemmons V Hickory Creek State _J2L_ Zip 76205 Check one: OD ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emoiovees 25 Name Chevron Stations. Inc. 5100 Rufe Snow Drive - Address V Oltv Hills Shrtn TX Tin 76119 Check one: 0 ADD EffectiveDate. 03/01/1999 QDELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Check one: 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Addraan 7502 Westheimer ruty Houston _ State TX Zip___77OS/2,. Check one: S"30 fcBteMivaOMa 03/01/1^99 DELETE Federal Tax ID Number_______ 94-0890210 Name Chevron Stations, Inc. Artrira* 733 North Loop 4 \ Number of Employees. 25 ______ fifty Houston TWCC 205 (Rev. 10/93) Pafleii of M .43008 \ W0RERS^bSte<8-TCNCCWMISSCf CK-1F45a (Ed. 12/93) Please Type LOCATIONS OF EMPLOYERS* BUSlNE88(El TWCCS TWCC20 Check one: name (U ADD Effective Date 03/01/1939 delete Federal Tax ID Number-- 94-0890210 Address. 2528 1-45 Number of Employees. 25 rati# Houston Qtato TX V" VJ---------- _ZlD 77009 Check one: ADD Effective Date. 03/01/1999 Q DELETE 94-0890210 Number of Emplovees 25 Name _ Chevron Stations, Inc. Address 2301 Fulton \. K ntto Houston state TX Tin 77009 Check one: [xj ADD EffectiveDate 03/01/1999 Federal Tax ID Number. Number of Employees. 94-0890210 25 Nna Chevron Stations. Inc. Address 5215 Richmond *^ Ctty Houston State TX Zip 71056, Check one: ADD Effective Date. 03/01/1999 "DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address. 9655 Westheimer City. Houston State. TX Zip 77063 pkaa!/ nno' - -- III add' ^.Effective Date___ 03/0L/1999_ DELETE Federal Tax ID Number--------- 94~ -------------- Number of Employees. 25 Name __ Chevron Stations, Inc. Address 8201 Katy Freeway v, C:lhf Houston State TX 20. 77024 Check one: 00 ADD Effective Date------0--3-/-0--1--/-1-9- 99 n DELETE FederalTax ID Number 94-0890210_ Number of Employees. 25 Name Address Chevron Stations, Inc. x 11525 NW Freeway ________ S&l -------------------------------------------------- City. Houston TWCC 205 (Rev. 10/93) Pagein of 66 CK-1F45a (Ed. 12/93) Please Type wij h iwdtetf--ww--"' ........ --MWMWWBBI LOCATIONS OF EMPLOYERS' BUSINESSES) TWCC5 TWCG20 Check one: name_ ---- ......---------' , 0 AD0 Effective Date 03/01/099 DELETE Federal Tax ID Number _ 94-0890210 Address. 12102 Veterans Memorial Number of Employees. 25 CMu Houston TX Zd 77067 Check one: d ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Address Chevron Stations, Inc. 7902 Ley City. Houston State. TX Zip. 77028 Check one: [xj ADD EffectiveDate 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name. Chevron Stations, Inc. Address _6606_Lawndale City. Houston State TX Zip 77023 Check one: 0 ADD EffectiveDate. 03/01/1999 -DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Chevron Stations, Inc. Name. Address. 619 Wayside City. Houston State__ 25__ Zip 7702l Check one: ~ 1 EltacUva Date 03/01/1999 DELETE Federal Tax ID Number___ 94-0890210 Number of Employees. 25 Check one: 00 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Name Chevron Stations, Inc. 5.0^ WofeHS-^SENSATION COMMISSION PleaaeTyp* LOCATIONS OF EMPLOYERS* BUSINESSES) TWCC5 TWCC20 Check one: Name Chevron Stations. Inc. O ATM3 Effective Data DELETE Federal Tax ID Number__ 94-08902IQ Address 5701 North Shepherd Number of Employees. 25 City. Houston State TX yip 77091 Check one: 0* Effective Data 03/01/1399 DELETE Federal Tax ID Number__ 94-0890210 Number of Employees. 25 Name Address Chevron Stations, Inc. 6707 SW Sam Houston Pkwy. City. Houston State. TX .Zip 77072 Check one: BAD Effective Date _0V0Um9_ DELETE Federal Tax ID Number______ 94-0890210 Number of Employees______ 25 Name Chevron Stations. Inc. Address 3002 Kirby X City_ Houston State TX Zip 77098 0 ADD Effective Date 03/01/1999 =>ELETE Federal Tax ID Number 94-0890210 Number of Emoiovoes 25 -- Address 2539 Bissonnet *Y rih, Houston State TX .ZlD.. 77005 Check one: g] ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees 25 Name Chevron Stations, Inc. - Address 7931 SW Freeway Vi ___ fNKy Houston State TX .Zip.. 77074 Check one: __ (XJADD Effective Date 03/01/1999 DELETE Federal Tax ID Number___ 94-0890210 Name Chevron Stations, Inc. Aridreaa M10 Cullen_______________ Number of Employees. 25 ______ HHv Houston SlateaS&v<Stc .7S051 \? ^ 7WCC 205 (Rev. 10/93) PaQeitl of J>6 TEXWWWWaWdEKR^SC-OUPB^AnCN COMMISSION CK-1F45a (Ed. 12/93) Please Type Check one: S A0D DELETE LOCATIONS OF EMPLOYERS' Bu5TnWS(ES)--- TWCC 5 TWCC 20 Name Chevron Stations, Inc. Effective Date 03/01/1999 Address 1002 Montrose Blvd. 94-0890210 T Number of Emokwees 25 nib/ Houston State TX Tin 77019 . Check one: jj ADD efectfve Date, 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of EmDlovees 25 Name Chevron Stations, Inc. -- Address 13303 Cullen @ Almeda Genoa VV Cltv Houston state TX Tin 77074 Check one: |xj ADD effective Date 03/01/1999 DELETE Federal Tax ID Number 94-089021(T Number of Employees 25 -- Check one: 0 ADD Effective Date 03/01/1999 QDELETE Federal Tax ID Number 94-0890210 Number of Emnlnveas 25 _ Name Chevron Stations, Inc. - Address 8001 Lawndale Ac Cltv Houston stats TX Tin 77012 Name Chevron Stations, Inc. - Aridraaa 10250 Almeda Genoa V Cltv Houston State- TX Tip 77075 Check one: ED ADD Effective Date 03/01/1999 DELETE Federal Tax in Number 94-0890210 Number of Emnlovees 25 Name Chevron Stations, Inc. - Address 6005 Jensen Cltv Houston state TX -Zip 77026 Check one: Name Chevron Stations, Inc. jx] ADD EffectiveDate, 03/01/1999 DELETE Federal Tax in Ni imher 94-0890210 Number of Employees 25 - Address 1401 Lockwood City Houston m CJ-' Zta. *>2A TWCC 205 (Rev. 10/93) Page 2425. ooff 66 *WORlCRS.'^M*fOKlATlON COMMISS CK-1F45a (Ed. 12/93) Please Type LOCATIONS Of^ EMPLOYE! TWCC5 TWCC20 Check one: Name Chevron Stations. Inc. 0 ADD Effective Date 03/01/199SL DELETE Federal Tax ID Niimher 94-0890210 3810 Little York \ Number nf Employees 25 CSy Houston State TX -Zip. 77093 Check one: 03 A00 Effective Date 03/01/199L DELETE Federal Tax ID Number 94-0890210 " Number of Emofovees 25 Name _ Chevron Stations, Inc. * Aaaresa. 7702 Windfern A Cttv Houston State TX ZiD 77040 Check one: - HI ADD Effective Date 03/01/1995 DELETE Federal Tax ID Number 94-0890210 Number of Emoiovees 25 Check one: [TJ ADD EffectiveDate. 03/01/1995 -DELETE Federal Tax ID Number _____ 94-0890210 Number of Employees. 25 Name _ Chevron Stations, Inc. Address 4390 NW Sam Houston -W- A -------- TT* Cttv Houston State TX .ZIP 77043 Chevron Stations, Inc, Name. Address. 14803 Katy Freeway Houston state TX Zio _ 77094 Check one: 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Address Chevron Stations, Inc. 5701 Ai toine AC City. Houston State TX Zip ....7.7091, Check one: OD AI3D Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 ______ TWCC 205 (Rev. 10/93) Pag Name Chevron Stations, Inc Address 71-7 North Loop East City. of .66 Houston lyon V V' {WORKERS' ^j^Q<3AnaN COMMISSION CK-1F45a (Ed. 12/93) Please Type LOCATIONS OF EMPLOYERS* BUSINESSES) TWCC5 TWCC20 Check one: Name Chevron Stations, Inc. 0^ Effective Date 03/01/1999 DELETE Federal Tax ID Number__ 94-0890210 Address. 1812 Ella Number of Employees. 25 City. Houston State TX zip 77008 Check one: 0" fc-Eltr .Iwanatt, 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employ es__________ __________ Name Chevron Stations, Inc. Address. 1702 Fountainview City HoustonState TX Zip 77057 Check one: El 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees___________2_5______ ___ Name Chevron Stations. Inc. Address 6333 Telephone__________ Cltv HoustonStale ^ Zip 77087 Check one: EUADD Effective Date. 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name. Addros Chevron Stations, Inc. 2601 South Shepherd City. Houston State_I2___ Zip --77098 Check one: 00 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Name. Address. Chevron Stations, Inc. 11102 Briarforest CK-1F45a (Ed. 12/93) Please Type COCATIOWS OF EMPLOVEag* BOI TWCC5 TWCC20 Check one: Name Chevron Stations. Inc. 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number__ 94-0890210 Address. 6783 Hwy. 6 South Number of Employees. 25 Cty. Houston State TX yip 77083 Check one: C3 AD .Effective Pete Q3/QI/I999 DELETE Federal Tax ID Number__ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address. 13648 Hwy. 249 <? Bammel N. Houston City. Houston State. TX .Zip 77086 Check one: GO ADD Effective Date 03/01/L999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Checkone: E3ADD Effective Date. 03/01/1999 ^DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name. Chevron Stations, Inc. 11101 S. Sam Houstci Pkwy. cty. Houston State TX. _ 73o 770.89. Name Address Chevron Stations, Inc. 2494 Hwy. 6 South (? Westheimer \ rtay Houston TX rip 77077 Check one: -j S ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number___ 94-0890210 Number of Employees. 25 Name , . Chevron Stations, Inc. Address. 14099 Northwest Freeway s ' Cty. Houston fitwte TX Zip 77.040- Checkone: II ADD Effective Date 03/01/1999 DEIEIE Federal Tax ID Number___ 94-0890210 Number of Employees. 25 _____ Name. Chevron Stations, Inc. Address. 15505 Wallisville & Beltwa' i^y Houston \ TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Pagein of 66 ^ IWOW&S'^JjlPSWIQN CCUMtSSC Please Type LOCATIONS OF EMPLOYERS' BUS! TWCC5 TWCC20 Check one: Name Chevron Stations. Inc. 0 ADD Effective Date 03/01/1993 DELETE Federal Tax ID Number__ 94-0890210 AdHma* 3310 Katy Freeway Number of Employees. 25 City. Houston State TX zip 7700? Check one: ADD Effective Date 3/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees___________25________--__ Name____C__h_e_v_r_o_n___S_t_a_t_i_o_n_s_,1 Inc. Address 9A35 Houston Rosslyn CMy Houston State TX zip 77088 Check one: 0 add Effective Date 03/01/1999 delete Federal Tav in Number 94-0890210 -- Number of Employees 25 ; Name Chevron Stations. Inc. Address 12405 South Gessner Houston City TX _ 77071 State ZIP Check one: E ADD Effective Date _ 03/01/1999 QTTelete ~ Federal Tax ID Number_______ 94-0890210 Number of Employees__________ 5_________ Name. Chevron Stations, Inc. Address. 11302 Fondren City. Houston State. TX Zip 77071 Check one: 0 ADD EffectiveDate 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees_________ H Name. Address Chevron Stations, Inc. 2100 Binz City. Houston State TX. ZIP _77004 CK-1F45a (Ed. 12/93) Check on 0 ADO EffectiveDate--0_3/01/i99g Q DELETE 94-0890210 Federal Tax ID Number------------- Numrar or tmpioynes 25 Check one: 13 Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 - Number of Employnns 25 ~ _ Check one: Jx] ADD Effective Date 03/01/193^ DELETE Federal Tax iu Number 94-0890210 Number of Employees _ 25 Check one: PH ADD Effective Date 03/01/1999 Q DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Check one: n00 ADD Effective Date DELETE 03/01/1999 Federal Tax ID Number 94-0890210 Number of Employees State ___ ZIp_2Zm. Chevron Stations, Inc. l/IHroM 12703 Bissonnett r.rty Houston State TX Zip. 77099 Chevron Stations, Inc. 11242 Veterans Memorial J--------- __ Houston CBy State TX .Zip. 77067 Name Chevron Stations, Inc. 15830 m Freeway City. Houston State-12--------Zip _Z2HML Name Chevron Stations, Inc. Aririrass 2750 N. Gessner CK*1F45a (Ed. 12/93) Please Typo LOCATIONS OF EMPLOYERS' TWCC 5 TWCC20 Check one: __ Name Chevron Stations, Inc. G3add Effective Date 03/01/1959 delete Federal Tax ID Number__ 94-0890210 Aridrasa 10855 Scarsdale Blvd. Number of Employees. 25 ftiy Houston State TX 71p 7 7089 Check one: J ADD Effective Oate 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees_______ 25 Name Chevron Stations, Inc Address 6102 Hwy. 6 =c Houston City___________ TX 77084 State Zip Check one: 0 ADD DELETE Federal Tax ID Number ___ 03/01/1999 94-0890210 Number of Employees___________2_5__________ Name Chevron Stations, Inc. Address 14647 Woodforest @ Beltwav 8 nsv HoustonState__EL_ Zip 77015 Check one: 0 ADD Effective Date 03/01/1999 "DELETE Federal Tav in Number 94-089021(T Number of Emoloveea 25 Name Chevron Stations, Inc. - Address 10005 Beechnut v-r i Houston State TX .zio. 77072 Check one: ADD Effective Date 03/01/1999 DELETE Perioral Tav in Numbnr 94-0890210 Number of Employees______ _ 25 Name Chevron Stations, Inc. A - Address 191 E. North Sam Houston Pkwy. pjh# Hous ton State TX -Zip. 77060 Check one: 11 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number_______ 94-0890210 Number of Employees__________ _25______ ___ Name Chevron Stations, Inc. Address. 19610 Tomball Parkway)G <SL-\ City. Houston j:. State, vtX PtjmG TWCC 205 (Rev. 10/93) Pape JLL of \^EXA8W0Ri^RRSS\<COMPENSATION C0MM1SS CK-1F45a (Ed. 12/93) LOCATIONS OF EMPLOYERS' iDSiSESSpST Please Type TWCC 5 TWCC 20 Check one: Mem* Chevron Stations, Inc. G3 ^Elfeetfc* Data 03/01/1999 DELETE Federal Tav |p Niimher 94-0890210 Address 4502 FM 1960 Number of Emoioveea 25 -- ntu Houston Stats TX 23d _7_7069___ Check one: 01 ^ Effective Date 03/01/1999 DELETE Federal Tav ID Number 94-0890210 Number of Emofovees 25 ^ Name Chevron Stations, Inc. Address 2329 Southmore fjltv Houston State TX Tin 77004 Check one: 0 ADD Effective Date 03/01/1999 DELETE Federal Ta* in Number 94-0890210 Number of Emoioveea 25 Check one: 0m Effective Date 03/01/1999 "delete Federal Tax ID Number 94-0890210 Number of Emoioveea 25 Name Address Chevron Stations. Inc. 1960 West 13155 FM ^ CSv Houston State TX____ Zb 77065____ Name Chevron Stations, Inc. A/Mmm 8902 Fallbrook Drive - omu Houston Qteto TX Tin 77064------ Check one: == 0 ADD Effective Date 03/01/1999 DELETE Federal Tav in Number 94-0890210 Number of Emoioveea 25 Name Chevron Stations, Inc. Address 4981 Hwv, 6 North ^ rSh# Houston State_IX____Zip .21AM------- Check one: 0 ADO Effective Date 03/01/1999 DELETE Federal Tav in Ni imhar 94-0890210 Number of Employees 25 Namfl Addraae Chevron Stations, Inc. 444 FM 1960 West Cty Houston \K \ TWCC 205 (Rev. 10/93) CK*1F45a (Ed. 12/93) PaQe.52 of _66 t^Swo^hs- ca*^ATiqwcoMMissa T s*' \ Please Type Locations Of employers- sosnsnes(Barr~ TWCCS TWCC20 Check one: Name Chevron Stations, Inc. 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number__ 94-0890210 Address m W Rankin Road JC Number of Employees. 25 City. Houston , State TX Zip 77060 Check one: UADD Effective Date 03/01/1999 DELETE 94-08902 lJD Number of Emoiovees 25 Name Chevron Stations, Inc. 15050 Old Humble Road Hf" CBv Houston State Zip 77396 Check one: [X] ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-08902TQ Number of Employees 25 - Check one: 0 ADD Effective Date DELETE Federal Tax ID Number 03/01/1999 94-0890210 Number of Emoiov# ees 25 Check one: ~ 0 ADD Effective Date 03/0171999 DELETE Federal Tax ID Number 94-0890210 Number of Emoiovees 25 Name Chevron Stations, Inc. - Address 18555 Tomball Parkway 2 Cttv Houston State_XX___ ZIP 77070___ Name Chevron Stations, Inc. - Aslrira** 13259 Westheimer A nttu Houston State TX .zip .mu.- Name , . Chevron Stations, Inc. - Address 4800 W. 34th & A1 \ flttv Houston State____Zip JJ.0fl?.,, Check one: HJADD Effective Date 03/01/1999 DELETE Faderal Tax in Numhar 94-0890210 Numher of Employees _ 25 Name Chevron Stations, Inc. )Q2^\ \ - Address 7225 Langtry - Suite 1C ___________ <2*SSrv City Houston TWCC 205 (Rev. 10/93) Pago 53_ gf 66_ K^^OUFfikSXnON COUMISS \TEXASW0Ri CK-1F45a (Ed. 12/93) \ Please Type LOCATIONS OF EMPLOYERS' BUSINESSES) QTWCC5 TWCC 20 Check one: Name Chevron Stations, Inc. 0 A0D Effective Date 03/01/1999 DELETE Federal Tax ID Number__ 94-0890210 Address 3941_Fondren_ Number of Employees. 25 C*y. Houston State--XX Zip -77063 Check one: -- Q"50 Effective Date DELETE ^ Federal Tax ID Number_______ 94-0890210 ^ 2q Number of Employees__________zz._________ Name _ Chevron Stations, Inc. Address 5959 Corporate Drive - Ste 3500 City HoustonStale TX Zip 77036 Check one: EADD Effective Date 0Vms99 DELETE 3 Federal Tax ID Number 94-0890210^ Number of Employees___________2_5______~~ Check one: Effective Date 03/01/1999 delete Federal Tax ID Number______ 94-0890210" Number of Employees______ 25 Name Chevror Stations, Inc Address 1619 FK 1960 East / City__ Huffman State TX _ Zip ,,7_H?6 Name Chevron Stations, Inc. Address. 110 First Street fitly HumbleStale--TX______________zip .... 7.71? 8 Check one: E TM Effective Date DELETE Federal Tax ID Number 94-08902101 Number of Employees__________ _25________--__ Name Chevron Stations, Inc. Address 5353 FM 1960 East City. Humble State. TX Zip, 77346 CK-1F45a (Ed. 12/93) Please Type Check one: 0 ADD DELETE LOCATIONS OF EMPLOYERS* BUSINESS(ES) TWCC5 TWCC20 Name Chevron Stations. Inc. Effective Date 03/01/1999 Address 1245 W. Pipeline Road 94-089021CT Number of Employee*... 25 Citv Hurst State TX___ ZIn 76053 Check one: [JADD Effective Date 03/01/1999 DELETE Federal Tav in Number 94-0890210 NumberofEmDlo' jss 25 ' ^ Check one: [X] ADD Elective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of EmDlovees 25 Name Chevron Stations, Inc. Address 1500 Precinct Line Road \ Cltv* Hurst state TX Zlo 76053 Name Chevron Stations, Inc. Address 9150 Roval Lane - Suite 170 Citv Irving state TX Zip 75063 Check one: ELADD Effective Date. 03/01/1999 delete Federal Tax ID Number 94-0890210 Number of Employees 25 .. Name Chevron Stations, Inc. 770 West 1-635 City Irvin State Zip. 75063 Check one: GO ADO Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-08902UD Number of Employees. 25 Name Address Chevron Stations, Inc. 1-520 N. Loop 12 City Irving State TX Tip 75062 Check one: [x] ADD Effective Date____0__3_/0__1_/_T_999 DELETE -- Federal Tax ID Number______ 94-0890210 Name Chevron Stations, Inc. Address 501 s- LooP 12 ^&\ TT . N,\v ^1 Number of Employees. 25 ________ Cltv Irving TWCC 205 (Rev. 10/93) Page JjJi of .66 \# TEXAS^ORKEfl? COHP^Nfi^3T^htCCN CCOMMISSI CK-1F45a (Ed. 12/93) LOCATIONS OF EMPLOYERS' BUSINESS(ES) Please Type Check one: TWCC5 TWCC20 - Name Chevron Stations, Inc. 0 ^Effective Date 03/01/1939 DELETE Federal Tav ID Ni imhar 94-0890210^ AQQr888M 2302 Walnut Hill Lane Number of Emota/ses 25 Citv Irving Stale TX ZId 75038 Check one: [J ADD Effective Date 03/01/1999 DELETE Pastoral Tav in Mnmhar 94-0890210 Number of Emnlovaea 25 Name Chevron Stations, Inc. -- Address 1016 W. Airport Freeway A' Citv Irving State TX Zip 75062 Check one: Ti ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emolovees 25 _ Check one: S ADD Effective Date 03/01/1999 "DELETE Federal Tax ID Number 94-0890210 Number of Emolovees 25 Name Chevron Stations, Inc. - Address 9150 Royal Lane - St Lte 170 V Cftv Irving state TX ZIp_ 75063 Name Chevron Stations, Inc. - Address 20003 Katy Freeway Citv Katy state- TX Zip - 77450 Check one: 0 ADD Effective Date 03/01/1999 DELETE Federal Tav in Numher 94-0890210^ Number of Emolovees 25 Name Chevron Stations, Inc. - Address 2303 Fry Road N. Citv___ KatyStale. TX .Zip. 77449 Check one: ID ADD Effective Date l--i nci ctc 03/01/1999 Federal Tax 10 Number. 94-089021GT Number of Employees. 25 _____ Name Chevron Stations, Inc. Address_ 875 South Mason City Katy S\<> /? ' OftV'j-'.'CA \- " %7450 v# TWCC 205 (Rev. 10/93) Page 56. nf 66 TEXA3W0RKHRS' COMPENSATION C0MMISS0 CK-1F45a (Ed. 12/93) Please Type LOCATIONS OF EMPLOYERS' BUSINESS(ES) TWCC5 TWCC 20 Check one: Nnrna Chevron Stations, Inc. 13* Effecttva Date 03/01/1959 DELETE Federal Tav in Niunhflr 94-0890210' ArMraoa 2303 Northpark Drive -V Number of Emolovees 25 Ctv Kingwood state TX ZIP. 77339 Check one: ADD Effective Date 03/01/1999 DELETE Federal Tav in Nlumhnr 94-0890210 Number of Emolovees 25 _ Name _ Chevron Stations, Inc. Address 1022 Hwy. 146 South Citv La Porte State TX _ ZId 77571 Check one: [X] ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210^ Number of Emolovees 25 Check one: ELf00 Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees 25 Name Address Chevron Stations, Inc. 6116 Lake Worth Blvd. Cftv Lake Worth Stata TX .ZIP 76135 Name Address. Chevron Stations, Inc. 6739 Lake Worth Blvd. City Lake Worth state TX -Zip 76135 Check one: ElADD Effective Date 03/01/1999 DELETE Federal Tax ID Number___ 94-0890210 Number of Employees. 25 Name. Chevron Stations, Inc. Address 4328 1=45 City. Lamarque State TX zip 77568 CK-1F45a (Ed. 12/93) Please Type LOCATIONS OF EMPLOYERS' BUSINESSES) TWCC 5 TWCC 20 Check one: Name Chevron Stations. Inc. 13 * ***.. 03/01/1999 DELETE Federal Tax ID Numhor 94-0890210 ^ Address 1463 Pleasant Run Road Number of Emoioveea 25 Lancaster State TX 23d 75134 Check one: {J ADD Effective Date 03/01/1999 DELETE Federal Tav ID Nnmhar 94-0890210 Number of Emoioveea 25 _ Name Chevron Stations, Inc. Address. 121A Bellaire Blvd. #121 fNjjy Lewisville State TX ZIP 75067 Check one: [X] ADD effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emokwees 25 -- Check one: 1^ Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emoioveea 25 Check one: -- GO ADD Effective Date 03/01/1999 DELETE Federal Tax in Number 94-0890210 Number of Emoioveea 25 Name Address Chevron Stations, Inc. 797 S. Stemmons Ctv Lewisville State TX Zip 75068 Name AMMromm Chevron Stations, Inc. 1099 W. Main St. -V ------\------ r'Wu Lewisville State TX ZlD _ 75067 Name Address Chevron Stations, Inc. 3700 Hwy. 67 ----^-- ruh/ Mesquite State TX .Zto_. 75149 Check one: (U ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees. 25 _____ TWCC 205 (Rev. 10/93) Page Name _ Addm.aa Chevron Stations, Inc. 108 E. Hwy. 80 "7^^ r>V \ City Mesquite of \ r' . ^ v T^WORKEkhcdMPeNSA'nON COMMI3SO CK-1F45a (Ed. 12/93) LOCATIONS OF EMPLOYERS' BUSINESSES) Please Type TWCC5 TWCC20 Check one: 0 AD0 Effective Date 03/01/1999 DELETE Federal Tax ID Number__ 94-0890210 Name Address uucvluu u uauxuno 1UC I 1712 Scyene Number of Employees. 25 pjh/ Mesquite State TX ZIo 75149___ Check one: (J ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Mama Chevron Stations, Inc. Address 18049 LBJ Freeway 1 CBv Mesquite State TX -Zip 75149 Check one: [X] ADD Effective Date 03/01/T999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name. Chevron Stations. Inc. Add* 9202 Independence City Missouri City State TX Zip 77478 Check one: S~ADD Effective Data-- Q3/Q1-/JJ99 DELETE Federal Tax ID Number 94-0890210 Number of Employees__________ Name _ Address Chevron Stations, Inc. 2420 A Cartwright ry Missouri City state TX zip 77459 Check one: S ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number_______ 94-0890210 Number of Employees__________ Name Chevron Stations, Inc. AHrtraaa 1717 Nederland \ Cltv Nederland State__IX___ Zin 77677 Check one: 00 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number94-0890215 Number of Employees25 - Name Chevron Stations, Inc. Address Rt- 2 Box 1625\ ^ \V City New Caney StafiC^Tft^ Zip ^357 TWCC 205 (Rev. 10/93) CK-1F45S (Ed. 12/93) Page 59_ f 66 TCXASWORKER^mip^NJDkTION COMMISSC LOCATIONS OF EMPLOYERS' BUSINESS(ES) Please Type TWCC5 TWCC20 Check one: Name Chevron Stations, Inc. 0 AD0 Effective Date 03/01/1999 DELETE Federal Tax ID Number__ 94-0890210 Address 7451 Davis Blvd- Number of Employees. 25 Hih/ North Richland qt>tn TX ZIn 76180 Check one: [3 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-08902101 Number of Employees. 25 Name . ,, ,,. Chevron Stations, Inc. Address 4815 Fairmont Pkwy. \ CJtv Pasadena state TX .Zip. 77505 Check one: 0D ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Address Chevron Stations, Inc. 6100 Alma A. City. Plano State TX Zip 75023 Check one: Effective Date HI!! DELETE Federal Tax ID Number______ 94-0890210 Number of Employees__________ ^5_____ Check one: HI AD0 Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emolovees 25 Name Chevron Stations, Inc. - Address 1101 Parker Drive Citv Plano State TX 7in 75023 Check one: HI AD0 Effective Date 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees___ ______ Name Chevron Stations, Inc. TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) Page 60. of .66 lWsWORJCfla^lPENSATlCNCOMMISSION \. \ Please Type LOCATIO? TWCC5 Check one:. 0 AD0 Effective Date 03/01/1559 DELETE Federal Tax ID Ntimhar 94-0890210 TWCC20 Name Chevron Stations. Address 1925 Dallas Pkwy. Inc. Number of Employees_________ 11______ _ cy PlanoState TX____Tip 75093 Check one: __ ADD Effective Date 03/01/1599 DELETE ^ Federal Tax ID Number 94-0890210 Number of Employees__________11--------- --- Name Chevron Stations, Inc. Address 400 Jupiter Road City Planograta TX 7?p 75074 Check one: 0 ADD EffectiveDate 03/01/1599 DELETE Federal Tax ID Number_______94-0S9021Q_ Number of Employees___________2_5______ - Check one: 0-*DD Effective Date DELETE Federal Tax ID Number 94-0890210 Number of Employees__________ H______ ___ Name Chevron Stations. Inc. Address. 6001 W. Parker Road City Plano gfotn TX Tip 75023 Name Adrtreaa Chevron Stations, Inc. 2121 Le8acy Prlve City___ EiS2 State__2-- Zip 75023 Check one: 03/01/1^9 DELETE -- Federal Tax ID Number_______ 94-0890210 Number of Employees___________25_______--___ Name Address Chevron Stations, Inc 3961 Legacy Drive City PlanoState Zip 75023 Check one: 0DADD h.Fff~th/anata 03/01/1599 DELETE Federal Tax ID Number 94-0890210 Number of Employees___________2_5______ Name _ Address Chevron Stations, Inc. 3649 Gulfway City Port Arthur c, \ v -.V j-T-6*2 TWCC 205 (Rev. 10/93) CK-1F45a (Ed. 12/93) PQ0 -- of 11 INKERS' KJNCOMMISSOf LOCATIONS OF EMPLOYERS' BUSINESSES) Please Type TWCC 5 TWCC20 Check one: Name Chevron Stations, Inc. SADD BfecSv.D*. 03/01/1999 Q DELETE Federal Tax ID Ntimher 94-0890210 Address. 3549 Twin City Highway *\ V Number of Employees 25 CMv Port Arthur State TX -Zip 77642 Check one: ADD Effective Date 03/01/1999 DELETE Federal Tev ID Number 94-0890210^ Niimhflr of Fmplnyeee 25 Namn Chevron Stations, Inc. Address_ 1400 E. Beltline Road \ Cftv Richardson state TX .zip 75081 Check one: S ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-08902101 Number of Empiovees 25 Name Chevron Stations, Inc. Address 501 W. Beltline A Cttv Richardson State TX .zip. 75080 Check one: EJ aDD Effective Date ----- 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Emolovees 25 Name A/Mroas Chevron Stations, Inc. 101 W. Campbell Road .a r.iUj Richardson state TX . Zio.. ,.7mo,.,.- Check one: S A00 Effective Date 03/01/1999 Federal Tax ID Number 94-08902 IQ Name.... Chevron Stations, Inc. Address. 2198 E. Arapaho Road _1_____ ,\ CK-1F45a (Ed. 12/93) Please Type Check one: LOCATIONS OF EMPLOYERS' BUSINESSES) TWCC 5 TWCC 20 -- Name Chevron Stations, Inc. E"" .Btaah.D... 03/01/1999 DELETE Foriaral Tax ID Numhar 94-08902ia -- Address 26026 SW Freeway Number of Emoiovees 25 ~ filh# Rosenberg State TX _Zto. 77471 Check one: ADD Effective Date 03/01/1999 DELETE Pwtaral Tax IH Number 94-08902 Id Number of Emoiovees 25 _ Name Chevron Stations, Inc. -- Address 2315 E. Northwest Pkwy. t nitv Southlake __ State TX ZIn 76092 Check one: GO A00 Effective Date 03/01A999 DELETE Federal Tax ID Number 94-0890210 Number of Emoiovees 25 ^ Name . Chevron Stations, Inc. - Address 2100 Southlake Blvd. Cltv Southlake State _TX__ ZIP 76092 Check one: ELADD Effective Data. 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees 25 A"Name Chevron Stations, Inc. - Arlrlraaa 17627 Kuykendahl 0#y_s.P=*SB ... State.. TX .Zip --12212.-- Check one: GO AD0 Effective Date DELETE 03/01/1999 -- Federal Tax ID Number 94-089021CL .. Number of Emoiov* ees 25 _ Name Chevron Stations, Inc. Address 8311 Louetta \ Cttv Spring_______ State TX Zip ___77379 Check one: HI ADD Effective Date DELETE 03/01/1999 --1 Federal Tax IO Numhar 94-0890210 Name Address Chevron Stations, Inc. '16702 Stuebner Airline . r' \j \ " \ Numhar of Employees TWCC 205 (Rev. 10/93) 25 __ filtv Spring - Page 62. of J>6 77373 jSyP' a- TESW0RKEflSr9^NV.TX C0MMIS90 CK-1F45a (Ed. 12/93) w....... : Pteaee Typ Check one: r~l TWCC 5 - [3 A EffectiveDate 03/01/1"-? DELETE Federal Tax ID Number _ 94-0890210 Number of Employees. 25 O TWCC 20 Name Chevron Stations, Inc. Address. 710 Sawdust Road City. Spring Stt TX :r m 77380. Check one: A0D Effective Date 03/0l/re9 DELETE Federal Tax ID Number__ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address. 103 Cypresswood Drive City, Spring State. TX Zip 77388 Check one: |X] ADD Effective Date 03/01/1999 Q DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Check one: Pn~AOp Effective Date. J)3/01/1999 Q DELETE Federal Tax ID Number 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address. 5034 FM 2920 CBy Spring state TX Zln 77388, Name. Chevron Stations, Inc. Address. 13811 SW Freeway City Sugarland State--22-- Zip 77478 Check one: (3 ADD Effective Date 03/01/1999 Q DELETE Federal Tax ID Number 94-0890210 Number of Employees. 25 Klamo Chevron Stations, Inc. 3651 Hwy. 6 _2_ ----------------------------- ------- --------------- ------------------------------- miy Sugar land state TX Tip 77478 Check one: [x] ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number.......... 94-0890210 Number of Employees. 25 Klamo Chevron Stations, Inc. 9902 Etmnitt F Lowery Address. nay Texas City \"t*" w ,^591,,, TWCC 205 (Rev. 10/93) Page 64 of 66_ TlIlQtSWORKERS^VPENSMIONC0MMISS0N CK-1F45a (Ed. 12/93) Please Typo LOCATIONS Of= EMPLOYERS' BUSINESSES) TWCC5 TWCC20 Check one: Name Chevron Stations. Inc. [X] ADO Effective Date 03/01/1999 DELETE Federal Tax ID Number__ 94-0890210 AMra** 5293 State Hwy. 121 Number of Employees. 25 The Colony State TX 7ip 75056 Check one: (3 ADD Effective Date 03/01/1999 DELETE 94-0890210 Number of Emolovees 25 ^ Name, Chevron Stations, Inc. Address. 4585 Research Forest Drive r Cftv The Woodlands State TX Zb 77381 Check one: 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-08902X0 Number of Emolovees 25 Check one: El ADD Effective Date 03/01/1999 "DELETE Federal Tax ID Number 94-0890210 Number of Emolovees 25 _ Name Chevron Stations, Inc. - Address 22610 Hwy. 249 -V Cftv Tomball state. TX .2313. 77375 Name . Chevron Stations, Inc. - Aslrlrna* 8424 Preston Road l -r Cftv Univ* Park State TX . Zio 75225 Check one: 03 ADD Effective Date 03/0171999 Federal Tax ID Number. Number of Employees. 94-0890210 25 Name Chevron Stations, Inc. Address 14810 Galveston \-- rytv Webster State TX Zio .. 77596 Check one: 0 ADD ^Effective Date __03/01/1999_ DELETE Federal Tax ID Number 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address 3136 FM 528 ^\ City. Webster .-W sQtd-. Zjp\ 7759t ^. TVVCC 205 (Rev. 10/93) Page5. of 66 8W0RKERS- COMPENSATION COMMIJ CK-1F45a (Ed. 12/93) Please Typo twcc*5~**'1 rwocao1**1*** Check one: ~ 0 ADD Effective Date 03/01/1999 DELETE Federal Tax ID Number__ 94-0890210 Nsme Chevron Stations, Inc. Adrift 1043 Bay Area Blvd- Number of Employees. 25 City. Webster State TX Zip 77598 Check one: ^ Effective Date 03/01/1999 DELETE Federal Tax ID Number 94-0890210 Number of Employees__________ ? 5 Name Chevron Stations, Inc. QUy Woodla ids State __^L_ Zip 77380 Check one: E ADD EffectiveDate 03/Q1/1999 DELETE Federal Tax ID Number 94-0890210^ Number of Employees______ 25 Cheek one: 0 ADD EffectiveDate. 03/01/1999 DELETE Federal Tax ID Number______ 94-0890210 Number of Employees. 25 Name Chevron Stations, Inc. Address. City. State. .Zip Chevron Stations, Inc. Name. Address. City. State. .Zip Check one: 0 AD0 Effective Date 03/01/1999 DELETE Federal Tax ID Number_____ L 94-08902ia Number of Employees. 25 Name Chevron Stations, Inc. Address. City. State. Zip Check one: Name. Chevron Stations, Inc. CK-1F45a (Ed. 12/93) i--------:-------- ---------------------------------------- --------- 1 INSURANCE CARRIER NOTICE OF COVERAGE/CANCELLATION/NON-'RENEWAL OF COVERAGE Insurance Carrier information Insurance Carrier Nurne Pacific Employers Insurance'Co. Federal Tax ID No. (FEIN) 95-1077060 TWCC Carrier MSI No. 3. NCCl No. 10677 5. Policy Type - El Standard C3 Divided Risk Typa of Transaction (check one only) O New Policy ~" CD Carrier 10 day Cancellation/Non Renewal Cl Carrier 0 day Cancellatloru'Nan Renewal __ Cl Correct! in/R*vision/Endorsement (attach TWCC-20A1 El Renewc Cl flolnatatement ~ Cl Voluntary Backdated Effective Date of Policy Employer/Insured Information 7. Primary Employar/lnsurod Name Chevron Corporation 8. Primary Employer/insured Business Mulling Address 575 Market Street San Francisco, CA 94105 8. No. of Locations and/or entitle* ooverod. (Exclude Primary Insured) 11. Employer's Workers' Comp Ctaea Code 1165 1321 1463 8742 8810 4740 10. Federal Tex ID Nc 910620053 12. Estimated No. of employee* 0-2 5 POLICY INFORMATION 13. PoHCy No. C4231805A 1 R fCavED Vwcc Effective Dates of Policy: fmnvdd*yy| "*pROM 03/01/1999 -*TO- 03/01/2000 Date Carrier Notified Employer of Cancellation: (mm-dd-yy) 16. Effective Date of Cancolt Uon/ReinsYaleme^^fllW^^) 17. Empioyer/lnsured DBA N 2 2 .1899 DIVIDED RISK INFORMATION 3 i t; i i f L