Document 91VDNvOa324N4y4VrwZ6xakD

LEONARD W. RILEY, JR. EXECUTIVE DIRECTOR TAMPERING WITH THIS LABEL NULLIFIES THE CERTIFICATION TEXAS WORKERS' COMPENSATION COMMISSION SOUTHFIELD BUILDING. MS-9&, 4000 SOI ITU IH-35, AUSTIN, TF.XAS 78704-7491 (512)448-7900 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 attached are complete copies of the IAB Form 9's(Notice ofCancellation ofCompensation Insurance) and LAB Form 20's(Notice that Employer has become Subscriber) for the period of 06-01-68 to 01-01-80 for: Southwestern Bell Telephone Co MBB9070111400 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 5th day of February, 2001. "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 It i* luwafep jg%M# tint fc'iwi im eUtnS Urn SovtfcMMttm MU MUyhaag, C*' ^' Irjtr 2-12OLtCY NUMt* < VT 220735* NS JRI.fi 1. Bits* !il*e*rle*l Msl,^ ami Constructla*,:Inc. 1320 Kr<** Boastoa, Ta* 77020 srrEcrive Etui 2-12-80 I FIREMAN'S FUND INSURANCE <' -'PAN? S0 THE AMERICAN INSURANCE C" *.?ANY i- TT-an NATIONAL SURETY CORPORAT-ON J *c'^>u ASSOCIATED INDEMNITY *. Fir '' - *TtON AMERICAN AUTOMC3ILE INScJHANC ,'MPANY PRODUCE* Mexuster & Altxsadm oi Te* Inc, JfouRtoa_f _Tt__ __________ ________ Vrj. NTrn'^citH^rywC O* AtJ?4biihl> ACCNT i3t**--Vi ^ !*? | , ' * 1QC30&-S-6S SET*? ZA.eery ,`i` r <#* - - :* AAS. .,, -t- iSS^i^S ,Km%ftAM*;ag'T1^ 11,^11#'^' Xt is hereby SZ**4 the* "the C<ki*ll*fcio &* co raJ 2fM Caxxect & Km*s?at> lie* el * '- fHSAfifit*a* c ,'iV. A'i ~PoDcr NoMn'rif 2-72 V? 2207326 ........................ !<-!!>!) ` ' ............ "TI fFEtCTIVC 1. TJcs Sluctric*! ftexlgn And CueatractLoa, Inc., Et41* 1326 Tiaii, Houatoe, T 77020 2-12-80 _ ~ JSSSSis-s FUND INSURANCE COMI-ANY CIIW THE AMERICAN INSURANCE CO*. `ANY 3-27-8 NATIONAL SURETY COAEOR.V'.'ON J associated indemnity c yrp', ti:on AMERICAN AOTOMOHtU iffl -VAN-' .- I MEANY Alexander & Alexander of Tex, Xne. !'oaton. Tax `MTl'/t ,f AUTHORISED AGCHT L._. . . . . '~??tyrL*yO /*, J^-euipt/ {f * ,-f ,IL .* '4 S 80002-6-69 se^s J.hQ.tvpy A 'A V- "* 3^ V' I I {Oftttactfr of buslnast in whloh afloapad) POLICY NUMBER... toe **-t OOPto, POUCY PERIOD: Prom - V- To 4-ut~re>'"' DATE OF CANCELLATION ~ 2-f 19_23_ HOUR OF CANCELLATION ________ (Month and day) DATE NOTICE MAILED TO SUBSCRIBER l/W/fteDH .............. /*,- Ot /. M: (Hour) (A.M. or p.M.) ...... INSURER ADDRESS fit peltry j CAStr*^rV som a'&m yen k (Full namt of Insurance company or association) S/1 At _______________________MOOSTOM, T'dZ'XAS (P.0. Box or Strast Address) (City, State Zip Coda) Dated at . > -V __ t Texas, this rNamo of city or town} /Sm............. day of * ** *hj 19. 79 r This form must be executed by the CARRIER promptly upon the CANCELLATION OF A POt, v of insurance under the terms and provi sions of the Texas Workers Law and mailed or delivered in person to the Industrial Accident Board - .tin t|#as If an employer r.eases to be a subset'!"-'' either because hi* pour, has *Apireri nr has tie*-- `eltita he shall mm or h#fore the date on which his pohe/ expires give notice to his tmj.ioyeos by posting notices to that effect m three p*.t *. places around such subscriber's ptant, and also to the industrial Accident Board A It F nun 9 (M*v 8 77) annular *14001? H*r G'apr><* ORICINAL COPY 4 i .M .uii W3K2S^'J^Ki!ii3itir.S2^^ _-'*rrs*C5XLlia ,, _'"" w SR. * JE^-^ 1^^[|^lglll8mi^^ H^[^y. SoudMesteni Bell Ueleptone Corapuy 308 South Afauri, Boon 1409 Dallas, TX 75202 i "V' ,-*vc-c This endorsement, issued by ono of the below named compar et>. forms a part of the policy to which attached, elective on the inception date of the policy unless otherwise stated herein /The mtormfiunn twin* ,% required only when , endorsement is issued subsequent to preparation c.* policy I Endorsement eth-rOve Named Insured Pohr* No Endorsement So Addit-ooai Premium In Advance $ f st Anmv % ?nd Anmv $ TOT At $ Return Premium in Advance $ 1st Anmv $ ?ed Anmv % TOTAl t riMiir iift^ Ct SEGA*- uttUHANCt COMPANY HOUSTON GENERAL INSURANCE COMPANY ECU!TABLE GENERAL INSURANCE COMPANY OF TFXAS Fort Worth T***^ /CIS! 740 QOG3 t t 7m; Sr*ai uu( >unters>gneo by f,iriMAi fAuthnn/wl Representative) 7 4 0 0004 (11 7a) V4n* *%**- i scope or coverage- 1} INTttt STATE OF TEXAS (All OPERATIONS} 3D PROWlET0*S AND-OR EXECUTIVE OFFICERS INCLUDED Si NOTICE f ,m OIVIOEDRISKPOUC.ES COVERING SPECIFIC JOBS joint ventures and foreign operations Must be FILED ON * A a FORM 154 O RElNSTATt^ENT REVOKES CANCFUACON EfFtCTv? OCCUPATION + INSURED- 'i\* I-phone Or Ve leqraph Co APPROXtMAH NUMBER rlf EMPIGHF1 W7r^^ ESTIMATEC ASNUAI PAYROLL i i 13 j / / j , 2 Z 'i. BELOW %.s* `RINCiPAt COkPORATt NA Vf- * INS t -.VIN<. HEADOUASI ' ; -*S ADDRESS. IHfcN tUT EVtRv SUBSIDIARY CORPORA?! *.N DOING BUSINESS IN TEXAS AND PROVlitf ITS PRINCIPAt ' -As ADDRESS A 1,0 U$T EVERY OPERATING OR DIVIS-C*' ' NAMF USFD IN TEXAS "NO MRMVIOt MEW location* :.'ntini. tr%. r'U ;earam . - j ' w> a* TAC>* bOUCUW'i 1010 v-t;> t , ` . . ; u H-it . 'OJ.irv RE C E i \H3ttSTRiAL KM * -.n'.Nitiw A ,t 5 M-*t '`SY* P "V. LntfAc*N *t m, iMpiiwItea* 1TO, aW'teiaiB^riHlhaiw wgT^Muw< <npYr tei bwiwC #M^aftrfjpMife<foulip|titeiatWtMi9MsHM to ampbpM otter (to tarns *nI l9te gjMaMl'W fiito Mid, jfeS KaM for_md feoi p*yte#w M "f 'lMW^ . I ,(OWMHni^^ - . fOUCYNUMBEt: iie-B-72T35 '53S35Sw= 't/9,, JW.VU5,. rt*$ 7$|31 war " EfrICTiVE: F*OM....... 1-1-78 TO OCCUPATION Or INSURED: Telephone or .. nim* 'AMY. SCOPE Of COVBIAGi: APPROXIMATE NUMBER 377 *909 Of CMPIQYEES: ESTIMATED ANNUAL PAYROLL:.1? jJ3_,72S t22k ENTIRE STATE OF TEXAS (AU OPERATIONS) jog ako/or executive officers included NOTICE; FOR DIVIDED RISK POLICIES COVERING SPfCIFK k)9S JOINT VENTURES AND FOREIGN OPLRATIONS MUST 8E FILED ON I A B. FORM 154 R E C EJ V E D REINSTATEMENT REVOKES CANCELLATION EFFECIlVF x AGENCY WRITING THIS COVERAGE IMMEDIATE PRIOR COVERAGE WaS IN EFFECT FOR PERIOD FROM THROUGH: (INS. CO.)_............ nt hjjuuj mn in uw com'*i SHOW LIST PRINCIPAL CORPORATE NAVc -ST OWING HEAD QUARTERS ADORESS THEN UST eVERY SUBS . iARY CORPORATION HO.NG BUSINESS IN TEXAS AND PROVIDE 'S PRINCIPAL IfXAS ADDRESS ALSO LISI EVERY OPERA!:NG , filVO'ONAi n-*v? USED IN TEXAS AND PROVIDE THHR '.O' 0;C* > S'N'IN LI51 ON SEPARATE SHEET AND ATTACH .'ou5hwes_tern _Heil TeLeo::. ,* _\..o: my lOlO Pine '.'.treot Lt. Louts, *'i GO S ifl O : POlifv NUMBIR r l. * V sii -frKf <{. t. / f \ mu r *t f-V.r'M m I|T * OSV o I'Os Ni" *.' , -,r l * t ! tii -h :-n m1 ha{of t l Wuev NUMSK* 1 WC-A-72735 | j EFFECTIVE DATC 1S:t *; 4-1-77 | CANCtULtO j INftUKANCC CO. TBtt a NEW POLICY O RENEWAL 3D EXPIRES AT 12:01 A.M. ON____ _l-.lr.78. Telephone or Telegrsnh Co. Office Employees & G OCCUPATION '" '' ~ 4GT OP 9RCKIP Cl* - STATE Z'f* Nobct. hereby given by **? named e - foyer ond t`e r-amed .n jounce vompon>, Ir.suianCi* /ct Chop'or 103. C-enerol 191? ond amendments thereto, that the- under yjtd Aj ond amendments rhere*' ,,ind provided for `he payment of componsc `htooof Any G ppnui'r a* -'-'t .> o oxiation - 'yMy fading oi refusing to file tho> ' ' V*> 'houC. Tm!-j '5* ha`` * >' .m-n offoruo sh:: ; m*d by >no .VorkmenX t"^mper'SOf''''' v> r has become o subscribe* to o*' 'ho forms and provisions * huh,*; 5 f *,r'C" pay to the 'dot** of Teron iF.MPlOYe* DON -ITS?? 1 I ,Y ^ I /V*^' i r> * --- ------Vv-r-/*- . . .t .* . * \ CA- -* 1 vso :-<.* ` noho }:*;{ _________... . 3fT!Ai " - -'V > i* N'O'l'E. r'.iill K\ I tils N'lJK.t . 0O: SOOATiON V' J;' ' ' ` f i t * i j 1 r JlMSURAMCF .NV ii ,N HERE ---...| ! i rex - Mp;.oetHfe.NSOsANCs: associat-on , AKO , MNri ' .* i OR ASSOCIATION Y ,K :'W, DALLAS. TEXAS 7522 unpnrs! 1 I &I !- t f /, i $ ? I V *" '. ' ~ " ' " ' ' , , , PARTN^ilS aA> SOUtPROPRIETORS ENDORSEMENT - team it is agreed that: ** t. Such insurance a* i* afforded by the policy 1?'liSli5ii,,!Sffite"islgssstct;. adofts does not apply to injury, including death resulting therefrom, mn.imrd by any executive office#, partner ot sole proprietor of the insured, except such, if any, as arc designated below or in item i of the declarations. 2. "Remuneration." when used as a premium basis for such insurance jicrrvrs nay executive officer, paitner or sole proprietor of the insured not so d< ncntlion of AUactive executive officers Designation of Persons APR 2 7 *77 TEXAS INDUSTRIAL ACCIOENT BOARD nt$ fftfftMKfit iMf tff Stbjtdfr III of ft teres, provisions ana conditions of tho Policy, and nothing ,-n* "n-c; -iliai! vary, a:!r oi ent(id any feta, D<9- Yiiloa ot condlhM of hw Policy oicopt u fwttio sptctflcaMy stated, TM asdotuatot, when sifted byadvty Avthortzad Riprosentstiwa of ft* Cuapany shall Iota a pail J ms&wmx------- -------------- --------------------------------- ---------------------------------------- ---------- -- ** . _________ Issiiad by tho TEXAS EMPLOYeftS' INSURANCE AfSOCIAIlOH of Dallas, Tuas ms aho swau. nd enrECtvc o* <dM) Mmi t im tioJieoTf 1 Doiios, Texas I the saat hour cf said data is the Sour of day piovided hy the Policy (nr coaatncoKnt ol the Policy Petmj, and Iris nndorsentni shatl terminate with the Policy. .IK.Xvh *>*; ; vv/v; ` "1 ''?&*' '`*1 ' ` "''i ^ V**'' / . ' ' '1 ' > EMPLOYERS SouthWQStefa. Ball:Telamone Company ' tesiaeM i* cooAeid) address 1010 Pine Street CP.O. B^s ot Srwst A<Mr*t) St. Louis. Missouri 63101 (dry, Hcnte, Zip OCCUPATION Communications Services (Cbsrscter of business in srhich engaged! NUMBER OF EMFLOYEES^Oj-900____ POLICY NUMBER____ ___ ^LrliL- DATE EFFECTIVE. June 1 ^Month and day* 19 76 . HOUR EI-rEOllVfc. ...... , *3:01__ Hour) * < !. orl'.M.) DATE OF CANCEL . AT ION April 1^________ 'dor.rh ani isy 19 ..`77 _, HOUR OF C 'NCf '. I AtlON 12:91___ AJA. ili-ii- \ M. ,.r F.V..1 IF POUCY RFWRi' TEN. POL'CY NUMBER____ EFfEMI'O i!'\H Texas Compensation Insurance Company INSURF.R * Full nro of insurance cx-spany or a**ouAUon ADDRESS .OS S. Aknrd I Texas J75C02........... Wtjfjs -d ., ' u XrlS IMS \ *- ..Texes ' . i -n:;.!*Ion Insurance Company , *v .u> j . - or as >ci.hw i r Bv_ S * ` `H !', .'Jeer -tary. t! ,1pA< $3$ 77 nl-f r ' rV y-KtPi-V(A,f w m am APPROXIMATE NUMBER OF EMPLOYEES: A. Stab)* Annual Employment:____40,900 B. Seasons. Employment by Month: JAM, Tel-- JUN `iK. I "<:! ! Telephone / l l^y VG t CCCU^A7K>S Marshall Kemp, General Agent, Texas Compensation Insurance Company A~~ar o' n " 'Okea " .................~ " AO' DftESS 3OB So. Akard Dallas ' state Texa s btc 75202 ktic* is N-'fOy (liven by tne iurr.e-1 employe! mi the named insurance company, as requited by the Tern Workmen's Compens4t.on Insurant:* Act. Chapter UP Centra) laws. 1917, and amendments thereto, that the above named s.itployer has become a subscriber 'inder vi 1 Act end amend mei>is there*;; and provided for the payment nf compensation tc employees under the terms and provisions thereof. Arty erecyer or association wilfully fatir.j or refusint to file tins notice Shalt be liable for end s tall pey to the State of Texas a penally of no! more than >. Thousand Dollars 1.000) for each offense. {EMPIOYE? SIGN HERE *t li i INSURANCE COMPANY SiGN HERE i jsiswD . '/7'^C - r->- iz^rc. f Texas Compensation lnsurer.ee Co. i *e** *, . m* i ml. *; .-i, 4 .. i * r Vice Presider,t-T>-x 'tri.' cr i t ms.1,. , |`,or'.SAr jfEcTlfyl r> I 4-7 b 108 do. Akard, Do lias, Tex as /'>2U2 | note **FRF ^NMirUTtl* KrflCf (iH JEHA!F Of cttfffdtsx r '-ri v rim s', fit h /ij* nvi; mhi u, >snt TEXAS r- 1 '.?!A!j ARO Secretary SIGNAIIiRl Mtpr '..ilNSTITUTES *:* :f I'm HEHAlt uf WIJWCF COM-i'.f OxC- JAL . Oh' 1 1-7S o NEW POLICY .. .1 ..... aipiKSIJ OATS llaMjyS | June 1, I97S e&s^saLtJto INfMBAHC* .CO, eg RENEWAL BCPfRES AT 12:01 A.M. ON June JiiJiffJL APPROXIMATE NUMBER OF EMPLOYEES: A, Stobin A/snsanl Emptoymanh____ 3ft '..ftPiL B. Stasonal Employment by Month: ~iXRT * ---- SmOT-- fTun JUL. AUG sIep. TfcX ~|--war" I' -wer Telephone _________ occupation MoraMil_Kemp^ General Agent, Texas Compensation Insurance Company ACT OH MOKU ~ AOCftisi CITY............................. STATE 308 So. Akard Dallas Texas sip 7S202 ftotice It heraty pvtn by the named employer amt the named tasutonce company, as required by the tern Workmen's Compensation insurance Act. Chepter 10], Stwral lews, 1917. and ncrendments thereto, that the above named employer hat become a subscriber under said Act aw wnendments thoretc ane provided tor the payment of compensation to employees under the lemu and provisions thereof. Any employer ^ msoeiatlon wilfully faltint m 'etusinf tu file this notice shall be liable for and shall pay to the Stite of feus a cenalty of not more than One Thousand dollars (ll.OOOi for *k* often**. ~ m eatftkf a4&w, b? Htf* pr *kr .Siaa&lijfi^^ ' ADDRESS; |K*AT!ON OF RISK; B ENTIRE STATE OF TEXAS O DIVIDED RISK--EXPLAIN OPERATION COVERED BY THIS POLICY fWV Nt)W>Wt errSCTivi OAT*J*:OS AM eAwcgtutP 1-74 June 1, 1974 O NEW POLICY RENEWAL EXPIRES AT 12X11 A.M. ON... .-1975. ' in*amcs APPROXIMATE NUMBER OF EMPLOYEES; A. Stable Annual Employmant: 4Of0B1 5. Seasonal EmnSoymanr by Month: JAN. r MA< AM' ! MAY" OCCUPATION Telephcsoe ACT, ON . . ,, ___ AOOItCS* ______ ....___ _ STA ft TIP Marshal. Kump, fivu. Tex* .C<4V. i;.. l'j. , jug L. Akard,_-a.;iL^a?Tx. Hoik* is r*iffc~ fvfn by (h ium#d Bmpioyci .i'..i ;t.<- >an;pi{ imuanca c:'"..>any. j require a ty f-a* texa SrHfcmen's Cor.'-ensation Initl^ince Yet. Chapluf 10,3, Cr -*fi U;, 191/, and iteronu'ii!k in.!;1j that >ha abew nai.iad employe! !> become ? tubsenber under Mid V.t and amend ments thaifto -,1 provided for Hie ...nrmen! *j/ eor'oer.sal.im in empty. }**_% under the terms i-C :v?v;iont the-eof Any ..'mployr-r or association wilfully >< irfusin* !u file Km ivdire -.nail be liable `or and shall :..i to the S!e*e -j` Ire-. 3 fruity of not mm* than One ''npejend Collars (Jl.dOC) for Mch itiense. cMPlO tR .n Hfftfc i!NS:,SAM;,,f ''UMrfy " .M HER' I SIGNED IT-- xa. ,Iul. IriXMI'.:. Sint T o J S I 1' A iJ* <L ji l.j^b I oa;e=. J ~WiTi>r > I I \:OTh . . tsn'.hf0- 'PL ?*': aSrr? tv<3vj^gj X" i I IHl *<.*j M Hi. Mi /../>/ WtfMi. ,i* U'7iu\7 u\ ijr'74 P7T '*n s injV.-iy^ivif.-ritmfti tuiiK'iSmHnTcUeTEcSoMNGwTirCrt J* ...r ^ ___!*_*_I crj.T.TTwn t! Eft* tfrdwa* n r^m Mm^u M crnmlm mem** *44tm, tew-a br *M M*r **** *-* *srtk"w r* ceufodfS * '* -- **"""* wdwraw*.1 learn. U v Southwestern Bell Teiephon^ Company 308 South Akard Street LOCATION OF R5K: ENTIRE STATE OF TEXAS 0 OIVIDEO RISK --EXPLAIN OPKATION COVERED BY THIS POLICY n NEW polio 0 RENEWAL June 1, 1973......... t EXPIRES AT '>:<)! A M ON June_A_ JS.UL APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annue Employment:_. _JJu .1 X* _ Telephone OCCUHATioiT" 'femihail r-'.m* A,'1",:' t(f* |*PCKt- ;en l ;X . C'Xfip, uiL ftetfc* *s hereby i'e* the *wn*.t sr.rj tv norvl tr-.^anctt <onr.--> '; Chapter 103, 0^*5 .**>. NP and ii!Twnc."*n!s ?Vrr*o *<,-i*f* \, -(**t *;r; * merits thereto **:? " i-A$4 *v p-ivit'a* * '* :o enmiuyee* <*>' fr.- 1 wilfuUy fading or *? . sr>j$ !t .!r- {<. ->.. ^*' *- thir *v ,413 pav * *h* Sl.OOCi for p\!ct ^"F? Ds1^0 J -.x_rct( Tex a a i.'*TE .tlP 7P - r\0 . i ^ - v,X r. amVt%. - **? 4 :s-rj As? amet.<` :' `'.Mi* An* employer at pv.ociatr.n :;W . >A* '-*\ja {jr,<r Thdu\4**- Dot*U ? $cMPl.OVG* SG^ j Mtjf |/ $ i /fi _ ?i' TA:: i, t *SPr fn > t .ut '** . ..iujan*. a , j: i * - ^C-rVvj S iri`A * ,"hau of ;v.u-Nt> : >MivN7 OCCUPATION V- l-iphon-j.............. ..... 4T ON SROKCN OOUH l '> ,' H zLklsOuLA*----C* . >j* ("'to.'*. iiy j .Aoca* * v '.. . w ti . i i.\J . i tJ4,f _ *1 t:X !teSie* it h*f*by |hft b)f tts* (lemed employer and (In Mtmd nsurance con(piny, is required ny the r i* Wo.'ime" - -peidniion fhiurinci'fct. Chapter IC3, tevfc-if Um, Il 7. and emendmenM tnereto, tint the itwve mmed employer hi become t '.uhic: -.-- ,i4et tjt<f Ad and wwfld- mmts thereto tf.4 provided (or to* payment cf ccmpeMLeinn to employees irdee (li terms and pr-mttor.s theref my employer oe annotation mlfvllf (ailir.j; m itfuimg to file tbit noik* shell be liable 'a* and tha|l pay to the State of Tean penalty of oof nn 'io thousand Dollars Sl.JCfll tor each offense. i INSURANCE COMPANY SION HE*J f - A0.JT *>f 9 .iMf*' P * * cj 'f. E'dTiruE or esntor tramtut -iofict ~F CiilVfc. -*rvr;T??: ::-*T |s;:wp- yyy 'AlUSf HttiE COHStlTUTES NOTIW US I1IHAII l.f iVf' ">m nr\ 1f `"V' N *TE k - HmVKN THIS sum i- <<< no (-mt am;/ no.it>>. ' r i i;j IDSE f *<V- - -'*} . O * . n"U t p,.,. t~ VIGINAL COPY a rrtAiImi * W flfH.'j* 'ef St . ***.* A.^'^usoSSBiS  APPROXIMATE NUMBER OF EMflOVEES: ' A. Stable Annuel Employment:......... I, Seasonal Employment by Month: rm --Tff-- SXI T~aHE~7"T-AT 1 tI ri JUN. ! rji. | ,MJG. | SEP. i OCI. ' nv. i' T" OKI. OCCUPATION .... Tfcl^foSML AST, on ftCKCK J. H. Ztamalt, Uonl. tsvsat, Texas `kip. Ins, Co., J08 S.. Akard, Dalle, I*jk_25292 Mk* Is hereby ttvw'i by the tamed employer and the v^ied insurance iorapiny. as required by the leitas WC't- >n s Crnpenssilon Insurance fct, Copter 103, General Lawt, 1S17, pad unml'-nwH thereto. Cart the above Mined employe; ba* become a niv Ki um.er said he1 and smend- ` thereto end pvMeS toe fee ptymtrt e apstttiw to imjAjiwt* mkr the terms and provisions thereof. Any employer or atiodition *Ufa/ fatSrn et refusi* to file this rn-tice hR be bafele for and >ha|l pay to the State of Texas a penalty of net mere than One Thousand Dorian $1,000) tor each offew*. ,ISMrtoym fmfcMM2 SlGNfD- E* D. Schodd ||NSURANC COMPANv 5IGh: rEM I Taxas Cr upensali | NnaAMMrr iOf- `NSUffj | DATE; `.Me Ppjaident-jfoxas_ ri'I.IC OF P?f>SON Sl^aiNC '.OT:r' Say.Sj 1270.. I ^ hi PC -nSTITtTJS NOT!!.* ON " (MPtCYTR | f 308 s. vGNtO: \ SKtr . x I - <>tt L m i i.ies this horii' E to i>> soi mail to ih-.>ru:;m O.utl) ! I novsr ,i .tONINO NOT ICC iilGNAHJifc Hm tJ-SSTITUHS NOTICF -Ki BEHAI * Of . W> CCWC fe --, o &oa m A. '-t < ORIGJNAt COPY OCCUr"AT'ON Telephone AaEwi or .iokcr ~ ~ ~" \## :- Mr. ^ -i--Hj. Zurw^uAjJJshariLJlesc.^_Teia/ Ccmp,, Xna. Co*, JOB.S. Akard 3t. Uallt-^ << Notice u furreby give* by the nomco empfoye* avf Hie flem*d insurance company, a% r >|vre4 hy :he "eret vYorkmeni Compen > ' < Art. Chapter Jt3, Gcnfi.i Lnt, !?17, end amendments thereto *t?at the abe*e aome4 employer hai becom* a iubscr-bcr under %ocd Act and arr * j.-n tn/rf for *h*r parmcnf of compenscttwft to *mpicy** tf*rr the term* end pro* .<>. `.r-t. <>t -f4' ufl A ' <K - V . / # Vice ..:< wan?*.?*. 3$ fiU.1; OF rMi- H K-i*. . N ,, U.-C V*rc 'ufe. * Net WhoM -.t *