Document 3NVVVo9718R306Yan6z0gGdgn
TAMPERING WITH THIS LABEL NULLIFIES THE CERTIFICATION
VIRGINIA A. MAY ACTING EXECUTIVE DIRECTOR
TEXAS WORKERS' COMPENSATION COMMISSION
SOUTHFIELD BUILDING, MS-96,4000 SOUTH IH-35, AUSTIN, TEXAS 78704-7491 (512)448-7900
PLAINTIFF'S EXHIBIT
STATE OF TEXAS COUNTY OF TRAVIS
CERTIFICATION OF SPECIFIED INSTRUMENTS)
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 attach is a complete copy of the IAB Form 20(Notice that Employer has become Subscriber) for the period of 04-01-79 to 04-01-80 for:
Standard Oil Co of Texas MBI#902090800
I FURTHER CERTIFY that I am the lawful possessor and custodian of the records of the Texas Workers' Compensation Commission of the State dITexas.
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
4th day of May, 2001.
._
"This document is signed under the authority delegated to me by Virginia A. May, Acting 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
NOTICE. THAT EMP&OYEftf. H^.ocowiwi
TEXAS WORKERS' COMPENSATION ACT
Notice i hereto c*v# bv tha n*nwi employ** and the named Insurance company, as required by Hie Taa Worker*' Cor ;......n" insurance Act. Cheal*/i<V).
OotwalLa**. t9l 7. ac*2 amendmenat*l.l.t.e..i.e...i.n.., .m...e.,t,ih na.S__ia_g_i_n_m_c_io_-_.-_e_t--baa faescmi a au!Ctlliaf ultArt and Avi-and amw-mis thereto and '`ovtdatl toy til*
iMvr.ient of comeanfcation to mptoy*n under tho term* aBd piovijlon*
*,fty nmplnyer or association wH'uiiy f.i
? 'efusinq4offit* this notkft Shan
nb*iaht* to; And slwsH oar to tha State of Takas a penalty ol odtmoce than Ona Thousand Oollaii ($1,000) toreach offense
insurance company sign here
<0O NOT USf. Gnotjn NAME)
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EM&LQYRS_IREuJfflS.U8ANCE^^EANY NAME OF INSURANCE COMPANY OR ASSOCIATION
POLICY NUMBER: FE G41_9_8.64_._________
P . 0. BOX 20666. _EL .EAS.O ...TEXAS.
AOjwjess
SIGNED:
SIGNATURE HERE CONSTITUTES NOTICE HALF Of INSURANCE COMPANY.
BE-
09 NEW POLICY
RENEWAL
EFFECTIVE: FROM 4 / L / 7 9 TO _4./l/8.Q_
AGENCY WRITING THIS COVERAGE:
________ -BIG...SPRING,--TEXAS.
AOORFSS _
'
I'HONS HUMBER
IMMEDIATE FRIOR COVERAGE WAS IN EFFECT FOR PERIOD FROM:TO,
THROUGH: (INS. CO.)_____ _____________________________________________ POLICY NUMBER: _ (NOT REQUIRE!) IE RCNEWEO IN SAME COMEANri
SCOPE OF COVERAGE:
--=g
'X ENTIRE STATE OF TEXAS (ALL OPERATIONS)
;: PROPRIETOR ANO/OR EXECUTIVE OFFICERS INCLUDED
NOTICE: FOR DIVIDED RISK POLICES COVERING SPECIFIC
cf?^ TM?.^VET*HvESAflB -"GREIGN GPEWWiOniS MUST ut
FILED ON I.A.B FORM 154
--
REINSTATEMENT REVOKES CANCELLATION-.
EFFECTIVE
. _.
_
OCCUPATION OF
INSUREO:. . ....Oil-Dealer.____
BOARD'S STAMP
i*
APPROXIMATE NUMBER OF EMPLOYEES ESTIMATED ANNUAL PAYROLL:
3
BELOW LIST PRINCIPAL CORPORATE NAME FIRST GIVING
HEAPOIIARTCO-. ADDRESS. THEN LIST tVERV SlfflSIDIARY
CORPORATION OOING BUSINESS IN TEXAS AflO PROVIDE ITS
PRINCIPAL TEXAS ADDRESS ALSO LIST EVERY OPERATING
OR DIVISIONAL NAME USED IN TEXAS AND PROVTUE THEIR
LOCATIONS CONTINUE LIST ON SEPARATE SHEELAND AT
TACH
_
H. W. WRIGHT DBA STANDARD OIL OF TEXAS
Box 30_______________________________
Big Spring, Texas 79720
+
i EMPcOYtH SIGN HERE ii | signed: . (NOT AVAILS3LE)
TITLE OF I'eKSOf.
NOTICE
i DATE: __________ _____
_____________
! SIGNATURE HERE CONSTITUTES NOTICE ON BE-
I HALF OF EMPLOYER
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I.A*. f"*i 20 <** *17J
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ORIGINAL
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f VIRGINIA A. MAY ACTING EXECUTIVE DIRECTOR
NULLIFIES THE CERTIFICATION
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!SI
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 attach is a complete copy of the IAB Form 20(Notice that Employer has become Subscriber) for the period of 04-01-79 to 04-01-80 for:
Standard Oil Co of Texas MBI#902090800
I FURTHER CERTIFY that I am the lawful possessor and custodian of the records of the Texas Workers' Compensation Commission of the State oFTexas.
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 ofAustin, Texas on this 4th day of May, 2001.
"This document is signed under the authority delegated to me by Virginia A. May, Acting 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.
_T
Do not remove any of the records or detach this certificatTon page. These actions nullify the certification.
An Equal Opportunity Employer
TEXAS WORKERS* COMPENSATION ACT
Nolle** ,, howB- even bv INI
employe* *niS the aetued Insurance company. * required by the Tfla WorireiV Cor ,..........:o,,, invaanco Act. Chol *rt3_
Gonentt
1917. nod me>dmertt*mi*fe!o. thM th* -m-rj employer -f-ta-a--b-e-c-c-r-o-a-a--s-u-b-s-c-r-ibe <kta iU Av.i ana *ni"':--ntr. thereto and r*ovidtd for th*
i?*vi*.'ont ot c<uTCK>n*AUcm to employee* under iho t*an*~and pioWnlons thar*of, Any ampinyer or association wilfully <a be imbtt> ter and slwlt o*y to th State of T***aa a penalty ot not more than Ona Thousand Oollftia ($1,000) tor each offun*?*
ci s 7eiusinq.ta'lileihl* nolle# *h*l1
INSURANCE COMPANY SIGN HERE <00 NOT USf. GWHJt* NAM
V Dr
EM^GYjRS_JZURE_JNs.urance_combany NAMfc OF INSURANCE COMPANY OR ASSOCIA.BON 0. BOX 20666. _EL .EAS.O,__TEXAS_ i Affpqess_ 79998
SIGNED:
----- -----------------------
SIGNATURE HERE CONSTITUTES noticC ON4 BE
HALF OF INSURANCE COMPANY.
___
------------------ !
POLICY NUMBER: FE G41_9.8.64_________
M NEW POLICY
_ RENEWAL
EFFECTIVE: FROM 4 / 1 /7 9___ TO _4/l/80_
AGENCY WRITING THIS COVERAGE:
PATTF.RSOM AflENHY TWC,
-- w NAM6
___^-BIG...SP EUNG-y-TEXAS.
aoouTss
i`m6"m"e number
IMMEDIATE PRIOR COVERAGE WAS IN_EFFECT FOR PERIOD FROM:TO. .
THROUGH: (INS. CO.) __________________ ________________________________ POLICY NUMBER: . (NOT REQUIRED IF RENEWED IN SAME COMFANVl
SCOPE OF COVERAGE:
=
:X ENTIRE STATE OF TEXAS (ALL OPERATIONS!
'' PROPRIETOR AND/OR EXECUTIVE OFFICERS INCLUDED
NOTICE: FOR DIVIDED RISK POLIC:ZS"tt)VERING SPECIFIC
JORS .IOINT VENTURES AND FOREIGN GPtRATiONS MUST Bt
FILED ON I A.B. FORM 154
____
REINSTATEMENT: REVOKES CANCELLATION
EFFECTIVE..................................................... ...............TE-______________________
OCCUPATION OF
INSURED:...............Oil-Dealer...____ --___ ________-
APPROXIMATE NUMBER
OF EMPLOYEES:
3 . ..
ESTIMATED ANNUAL
PAYROLL:----------------- $42,600.-----------
BELOW LIST PRINCIPAL CORPORATE NAME FIRST GIVING
HEADONAPTFOb ADDRESS. THEN uSI EVERY j*DBSlDlAaY
CORPORATION 0OING BUSINESS IN TEXAS AND PROVIDE ITS PRINCIPAL TEXAS ADDRESS ALSO LIST EVERY ITERATING OR DIVISIONAL NAME USED IN TEXAS AND PROVIDE ThEIR
LOCATIONS CONTINUE LIST ON SEPARATE ShET AND AT
7ACH
"
H. W. WRIGHT DRA STANDARD OIL OF TEXAS
Box 30______________________
________
Big Spring. Texas 79720
I EMPLOYER SIGN HERE r J
i SIGNED: . (NOT AVAILABLE-) _
I
I iti
I ................... nlLE OF FtKSOr.
NiHICfc'.....................
! 0ATE: ___ ____ ____
_____________ _
! SIGNATURE HERE CONSTITUTES NOTICE ON BE-
j HALF -OF EMPLOYER
!
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ORIGINAL