Document By774eepEo5GLwmyoeJwnvkYk

I S RA I tWiKLUT trr^^fjcgyuvit ^U^UHItltK TEXAS WORKERS' COMPENSATION ACT Orlginiil to Industrial Accident Board 200 E. Riverside Drive, First Fluor Austin, T ex ns 78704 f\ 0 Nolle* Is hnreby fllvnn hy ths nnmcd Insurnncft company, as required by the 1 nxitt. Workers' Compensation P.si.mn n act. Chattier ton tienprai I ae-s. tot T. and anfnilments thr!0. that Iha onm^d oroployor has bncnme a Mibacnbar undnr said Act and amendments thereto prrxdd yd tor thr paynetii of romr'.nsatton to mploy**PA under ihc term* and provision-* ihrreof Any insurant company Volina to litn this roue* shall ne II shin Ini >ud *n*u pay tr> f** <i;ai m t 0**1 ^ penalty ot not more titan Ttve Hpwjrort OoMarA (J5fXtX>) for each otfenso iArtlci8106, ma amendrdQ.t 811 The covp/aoc wiM emain *n et'oot until Nebco of Cancellation or Nomenewni of Compensation Insurance (IAP Form #9) is tir'd with the huiustrMi art toont Boarder until suhseciur-ot nollr ot covnraQe is fpomvnd by iho IndusUij.S Arurtent Roard (Article 8108. /0a, amended 0 1-83) INSURANCE COMPANY SIGN HERE (DO NO* 0801 tP NAMf \ imi'l'-vcrs Insurance of WausauLA Mutual Company NAVf fu IMM UAMf % AM* 'P AS<'oMAU|'N 1633 Broadway, New York, NY 10019 SIGNED SIGNATURE HERE CCfl't'Jllflnes NOTICE ON BE HAI F Of INSf IRANCE COMPANY POLICY NUMBER EFFECTIVE FROM 0515-00-094689 2-1-84 a NEW POLICY PRIOR POLICY NUMBER 0514-00-094689 O REWRITE____________ (Prior notify M-Mwtv* j AGf ncy writing THip covprage kinployors Insurance of Wausau* A Mutual Company NAMf 1633 Broadway, Nov York, NY 10019 (212) 489-7500 Af>r-pr ' PHONf MUMBfh IMMFPlATr PRIOR COVFMAG* WAS IN EFFECT FOR F'ERtOO FROM TunOUGM HNS CfM iHOt Af 0MIBFO ir RfNfWfO IN SAMf COMPANY) 5 >1 ICY NUMBER SCOPr or. COVERAGE K ENTIRE M ATE OF TF.*A^. (A* l OPFRATtONM rj pnopntcTQR and onrYrnjTivF ortu fr-included K'CMU rr>B DIVIDE!) RISK PQUOFS Ofn'tniNG S^F^FIC JOR. .HUNT VENTURES AND FOREIGN OpfRA'igNA rur-non a.: formic n RFINS1 ATFMENf REVOKES CANCEL l A f)M rf EPf ECTIVE , _ .. UCCUPA1ION-OF INSURED . v Printing ANY ADDITIOIi -' a DFU TION '>' A SUBSIDIARY CORPORATION WII I, REOUIPE H'Mfi "ATF Nf.Ttr r TO THE ROARD GIVING DATE EFFECTIVE A '-',`it'TOIBFP MIAll NOTIFV THE BOARD OF A CHANGF or NAME r'U Afit-ot i . BOARD S STAMP RECEIVED JUL 1 o 1094 !T.dL'St,_:3! -' 'L ! I I 1 1 BELOW List PRINCIPAi CORPORATE ';fV! f .R'O GIVING ME ADOi IARTEPS ADDRESS THEN OST EVERY'SI IRSIDIARY COR PORATION DOING FUISIME S f: ?L'A> and proviDF I'O : RiNC u-A.. te*AS ADDRESS ALSO LIST EVER'' OPERATING OR DIVISIONAL NAME irrp Itnr .and PC 'HFiRlOr AUOflS cot; TIN- Jf l.rT on SEPARATE SHEET AND ATTACH EMPlOVFB-INSlIRf.O . . _ ................................................................... American Can Gonipan v American Lane Greenwich, CT 06830 American_Ca_ita"l Asset Management Houston, TX____ ____ _____ ______ _ IA6 Form 20 (RFV 9 M} (H>3*9?J>6 J83 ORIGINAL COPY NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER TEXAS WORKERS' COMPENSATION ACl A, N&tlce Is hereby plven by the npried employer and the named tnturanco company, as required by the Term* vV^ifcnrV Common*,tnM>in/ n Act Chapter tnj Gene'll Laws. 1917. nnri amenii''*' is thereto, that the named employe* han become a subsi iber under aa'1 Af.l and anentmini*. rtH*fgu .mo ,,;ovlrtHd ter the pavrre; c i ompenaai.n*1* to emptevneR under the terms and provisions thereof Any employer o' association wilfully tailing >r u-'i.m! .. >< Pus not i c r.ait bn h.-hta rr>? a -,i f.a\ *o thp State ot Texas a pnnalty of not mom moi On Thousand t)n?|ars (J t OOOi lor each nffnnsr* + ----- j INSURANCE COMPANY SIGN HERE | ,rvx *.,.> t ijo/uir *rAMi` ?i ot rrik iN^nnAN'f rr \vaij;aii a mi.ii o * | ' ' .*,A-' A*l II*. 'JMfltAA'l I . No . J WiM' * ' | - .i ,i.Air /... #*.* nt isuiviavi 'yrA`i *(> aaso* ! 1633 Broadwtiv, NT fT 10019 | \* 5*KNF V I i ' in j SlGNAI**n HfR| I < I < ? 1I P'. bOTIM MN pf * MAI f f `NMlHANn l 'VJl'Htr* + j REVISED 2/1 POLICY NUMBFR 0516 00 094689 EFFECTIVE. FROM 2/1/79 Unit1 Canceled NEW POLICY PRIOR POUCY NUMBFR 0514 00 om',689 REWRITE AUfNC/ writing tmis ( OvfOAGF k *' 16 33 Froatlwav, N'f v YnrV, NY 10019 . r nj r *!"' `j ( .,i V/AD'.AIJ (212) 489 7500 iMMt f)tATF PRtf'P * WAS 17) T * '>* pfttinp r ROM mfvmr.M iin' r t * i iMOi nr mi**pi n pf n wi n *a sami (ami**n POI ICY MIJMftfM TO SCC'PF or C-OVFRAC.F X FNTIRF STATE Of T* *a<, ,-au * rf UA r *ON5 rnf*pp(CTr)R AN! * OR r v {f \: * *. ;)tt- fo(; iNr.l i jf-f ( NOtirj t OR OiViDFIfp ms* POiiriF^; r OVERINO c'PFCft f r IV EDJOBS **C'NT VENTURE,.5 AND rnpf H.M opf rations M*jGT Hpfc y t ni 10 ON A B FORM i54 REINSTATEMENT PFVO^FS TAN'MIAT EFFECTIVE Ji;i U'84 occupation of insuE0 Can Mfe. j^strial At cidwit BORtl Auna .ANY ADDIT'ON OP DEIET>ON OF A SUBSIDIARY CORPORATION WILL REOUiPf IMMEDIATE NOTICE IO THE BOARD GIVING DATE EFFECTIVE BOARD'S iTAMP |m ' -,v l*.,' :'i) j 1. .ji ' Af fj'itn-i !> ._'M!i ' - . . - SoI'VpiAP. C.OPF(FI,-'*'i''!, i r-m.j?-;'a- 't\r- z ; t Aj'; ffCV'Cic P*j .t r,i. - OP l>iV<;iO;.'.; '..`.vf .r . . . Ai{ Iwt-:- I OC ATI.>*.' 1 . * ' Ij a 11 ' i.t l T /.`Jt. A- TAP.H Ameilean Can Company American Lane_ _ _ Greenwich, CT Oj6830 _____ (Corporate Headquarters) __ SEE ATTACHED............... I EMPLOY R .SIGN `il E ! sign FQ I I DATE I t 41 GIGNATUPE NOT REQUIRED IF NOTICE IS SIGNED I BY INSURANCE COMPANY +----------------- ----------------------------------------- *-------- --------------------------- II IA B Form ?0 ine 6 7^1 (N) 3ri-?l9f. !> /P ORIGINAL CORY WAUSAU INSIIRaNCF companies ENDORSEMENT <r Invc&e N'jiabtt o* Policy Numbm 051m ti>>u . v t f! No . : |,4 Named ln*tirptf 4id AMfRiv *'' . "i, */*iWs>" OSH* C'/V-T A/i?j ,v f *>t ;; *1. '' r,p"' . - * -?' Thit Fi'dcrjwnif''t Policy Pennd ; lnvrw'Pi*r,s *'** * v> ** '; * m t T P)Cw!" /' A* f.XANOCR ALEXANDER '> i'OUNrcTK'ijr, me. AU`h.i AM Adrift ' * 2:d v.*n trrmmaie with th*> policy. J ? 5t,A K*. nfnrtnrd fnp *? the addicts of the wtmnd insured u sin ted hte>n. Vr^/A ; * t-V > **` .\M-hM' V, ' *'*; ''HO jn 0 jf *P ED ALLOWS: REC'D poor quality RECEIVED APR 3 0 1984 PRF^H^' Ti> pc* All ot*'pr provider* arf vtrti?. remg.r, urvAnQ'd Industrial Accident Board lued by h* :?mp8ny provuii.'-, :h* uwiranm .-Hr-Art }jV poh'-y a: dw ijn**pd n tba declarations paga made* part hereof. 1635 BROADWAY, HEW YOR, NY 10019 Sis Cl CKind V/ PK 500 / H NY,HLU C AT,PO,PHX,NOL,SE, Co LA, DEN, BEL, PH, BAL, 0L,RF,1N,KC,W,DE,TC] t I* i L/Cov T '> St .'U)i5-B? 2 84 \ fy'c Corm w.c Tox Out. P.P Clan 5L, N-J, DAL, SYR, NY, C, OKLA,HOU,ML ' Bur. C, DEL/4W,INB,m,MI,M,NYB,NC,PA,TEX, W i Au> n Premium i i _t 12 Cr X Yr. BROKER COMMISSION Percent Amount Cr. s :1 Hlwucd: 4 17 84BB/EB (M) 15-5724-1E 10-81 H-AI'SM' iVMI't \,\(T t OMrANP-'S Sjreau or si a rn authorn v copy FMOW'vStrJT Invoice No..-.;-*, Policy Ninohp: |.r Assn f "i! n 0 F> 1 ^ fM 'i5- !!. Ns air if IuhittI citi AHdrrii /V*f !; ; i' i ! iy.H'-v f--,[ " M* hi ! i '.-i '-ir.M'h Cf it11T. N''AT I ON I Pindnret A| f'VAMOfR r A! EXANDFR < r ^ pd' ( T]C.IJT, INC, Annont 0<>v $ AIuhfl This t rvlnir. '"vn.'.r P''licy P*fi<iP . 1 sr >ri,OM,pfR6` >3 P ->*! :* : " Ani-iP-ioi .H )NTHLY F ors? *.v!: jnrminale with thp policy. . ' t (M A V,. i.ctp a! t-- address of the named insured os JtatH hrein ( A'-T'.r.r .AC :v'< / ?.}<\ ' RECEIVED APR 3 0 1984 All Other prOVU'OnS a-H "n' ..'.s rarr-e - ]V]r (, TV] If; ' "lF Industrial Accident Board Austin Issued by <>'? copipjay prpvirtng in* -- -ro -`rri k-. jh.- rvT-.v as detonated on the derlaretinns page made a part hereof sis Cl 0 Kmc P'S 'Vi IS62 2-M ^ ---- f' , R NY,HlU C AT,PO,rMX,NGL,SF, LA, DEN, BEL, PH, UAL, OL.RF, IN, KC,W, DE, TC, 5L, NJ, DAL, SYR, Co Auto iSl. I :Coma w.c. Tills O'St. P.P, Cfcu ! --! 1:1: HY,C,OKLA,HOa>lL Bur. C,DEL,MW, INB,MA,MI,M,NYB,NC, PA, TEX, W,NJB Premium Div, Vr. broker COMMISSION Percent Amount Cr, % Issued: 4 17 34BE ) ] 5-5724-1E 10-81 %****> **tafe, * I y$0S&&i&rf'' ENDORSEMENT P,.;ORKMFN'S compensation l,., 11 N'timhw invoice Oatr f>t hey Funtbw An Em*. Nn O', <3 -JO 0D;>:''<) Of1 66 Nir-f'i myjrfri a-J Addinss /-veric-':: cam company ''CEE ENDORSEMENTS <`1, ?, 3,( ,E. AV.FR I CAM LANE ' r.MIC-i, CT lf.fiwi lt"~) 1 2 . Pfr.dtictr X 3155 ALEXANDER C ALEXANDER OR CONNECTICUT, INC. Audit Pt'ind: MTNTHL Y- F Amount Due Alpha Co*** T^i? niotspmr.pt ii ptfpr.rrvp 9 1 8? Poi>CV Pwiod- Iriv'i'ca rNrmg Fpfiod ? 1 >? 1?01AM. and w>H terminate with the poKy standard fme at the addrpts of ihp namen 'timed as ttattd herein. CHAT jr,E ' h f).% S EMEN T IT IS Afiorrn THAT ENDORSEMENT .`"."HERS 1,2 : ARE AMENDED . FOLLOWS: ENDORSEMENT a j / A-rXT: f>> TRANSPORT LIFE INSURANT rf. HOI DDIINfiOr. rrrvtTpAiV!,!V TRANSPORT LIFE INSLPAN'.r Cn`'PAfV r- ^ LA'I TED CAPITAL COPP-iRAT KN 0W A. ) COP.C V JE T INVEST ME NT CO>. " s,\ B. HARWELL F. ASSf'CIA";', INNCC.'-.-1- , CONTINENTAL LIFE INSlPANOS COVPVIY'rl A.) HIGHCREST REALTY CO`'PA.\Y f> . AMERICAN FINANCIAL LIFE INSURANCE COMPANY Q l JIM STEWART & ASSOCIATES ENDORSEMENT NUMBER 2 IS AMENDED AS Hi^lCWS: ADD. TRANSPORT LIFE INSURANCE COWY CONTINENTAL LIFE INSURANCE COMPANY o' ENDORSEMENT NUM3ER 3 !<= AMENDED AS FOLLOWS: RECEIVED ADD: TRANSPORT L!CE INSURANCE COMPAT-' CONTINENTAL LIFE INSURANCE COMPANY HARWELL ASSOCIATES, INC. dec; =? FORM NUMBER 10008 AH other provisionsanrf conditions remain unchanged kjusvrw A:.'>'PlBMrd Indii: Issued by the Company provirfinq the insurance afforded by this policy as designated on the declarations page made a part hereof SI.CI 0 Kind R NT,HLU (M) 15-62 7-91 PRTO. USA 52 PK 300 Li.: 3 ! ' , 2 . 6 :| |_Co. *L/Cov jT j St. j Tax Dist. Au* Ctl CCWiSSiON P^rr,--t c HO, LA,SF, PH,BAL,OL,l_ AT, IN, KC,W,DE,SL,NJ,DAL,C,6EL,DEN, NO!.,HOU,LR,TC,PHX, RF,NY N Iswed 10 1-* S2S Bur.MTCAZ,CO, ID,NM,UT>,C,NB,DEL,MA,FLA(SE,INB,NCE,CSCK),MI,CS(MO),NC,OK,PA,VA,W,Trx.`-: : ARK,NW, IL, MASS,M,NYB,SC,NJB CHANGE Or NAME ENDORSEMENT Whprever m the policy, certificate, or bond the name EMPLOYERS MUTUAL LIABILITY INSURANCE COMPANY OF WISCONSIN is used, the name EMPLOYERS INSURANCE Of WAUSAU A Mutual Company is hereby substituted >, _rM (010) AMI i. iC t*. ( AN C'TMPWY A m f i' 11. a *. i. a \ r M- I = \-n I r .1 i AM ( 7 I CUT -M, > '(, All ollu'r provision-- and roiiriilions remain riu hanped * > > In Witness Thereof Hie LMPLOYFPS'UMiRAIIU Id 7,"Air .A'! A Mulu.il Cnnip.iii-, iio'- In i. ni"',.>!`'i" *i 1 Wisrnnvn f--f.ii)il |h.-. (.iinrif r>! f;-:rn<- tml.i- . n., ji , n! ;) In --n n( VpN n>h>-i i<i/-i i' tt, n;.p|i ft Q ui/ * Si'ct'-lary "" efr i < 80 >h o ;m v) 11 **$?* >*fl NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER TFXAS WOBKFPS' COMPENSATION ACT l -------------.gqilU. --- ------------ Notice s hereby given hy the named employer and the named Insurance company, as textured by the lexas Workers* Compensation Insurance A * Chapter JP3, General Laws, fpi 7. and ame.iumenls thereto thatt'^r-imodwnp'oysrhasbar.omoa subsc'lbei under said Hrri .imonrirnents thereto and p*ov*ieri lor the Daymen* qi compensation to employees under the terms and pTovt.-iiOns tKerpri Any employer rr nssoemhon wilhiUy */Hmg n re,n<mg to Mo this notice shall be liable lor and shall pay to the Shu* M Tov.os ; enftUy o( not more than One Thou ..r>d Dollars (Si 000) loi each offense 4 POLICY NUMBFR . _5lO 00 ^9531 INSURANCE COMPANY SIGN HRFifc n> t^r n.vrfjr rvAMfi wyriwt UAHiiHv powpanv or viov.onvn , i .*;*. ntr-imum WMm'tf't e JVAU`.'-P Fmployers Insurance of Wausau .*asf m Acpwi*<f i . i.*j`AA>f .-.n A^er-Atms L>')33 Broadway, New York, try IOOI9 NEW POUCY &) RENEWAL EFFECTIVE FROM ... ?_j____TO 2 1_80 OCCUPATION OF INJURED. _Can .Mfg............. ... signs r; MONA?URF HERE GONP! ImTh ' NOTICE ONRFHAU or in-,, .RANT COMPAN1- APPROXIMATE NUMBER Oc EVPIOVEES ___.1,200___ ESTIMATED ANNUAL PAYROLL' ,,4-12,000,000.-- SCOPE OF COVERAGE 0CFNTIRE STATE OF TEXAS IAU OPERATIONS) O PROPRIETOR ANO'OR EXECUTIVE OFFICERS INCLUDED H NOTICF FOR DIVIDED RISK POLICIES COVERING SPECIFIC JOBS. JOINT VENTURES AND fOpripN OPERATIONS MUST RE .FILED ON I A B FORM 154 Of N57ATFMFNT nrvOKFS T.ANCFU ATION KFECTIVF . .. , _____ AC-i N> . WRITING THIS OAFRAGF EJ TMI'I OYfR*-, MUTUAL Li ABU 1T y INSURANCE COMPANY OF WISCONSIN H LINO'S f VT'i C'- FRS INSURANCE OF WAUSAU 1633 Broadway, How York, NY 10T19 (212) 489-7500 AtONE NUMBER l/P!A7f PRIQF. COVFRAGf WAS ,S FT Fr I TOR Ff PlQD FROM .... ___ TO THROUGH - INS CO ) (NOT REQUIRED If RENEWED IN EAME COMP,N>> POLICY NUMBER ____ _ BELOW LIST PRINCIPAL CORPORATE NAME FIRST GIVING HEADOUARTEPS ADDRESS THEN LIST EVERY SUB SIDIARY CORPORATION DOING BUSINESS IN TEXAS AND PROVIDF US PRINCIPAL TEXAS ADDRESS ALSO LIST EVERY Operating OR DIVISIONAL NAME USED IN TEXAS AND PROVlDf. THEIR LOCATIONS CONTINUE LIST ON SEPARATF. SHEET AND ATTACH American can Company American Lane Greenwich, CX 06830 EMPLOYER SIGN HERF SIGNED riTL o eresow signisr sott? OATE ______________ SIGNATURE HERE CONS'T7nuTl'ff$ ON DEI CAS r OF EMPLOYER Locations; 2801. Last Abram,. Arlington, Texas (Plant 054) Clinton Sc. Lockwoo.i Drives, Houston, Texas.77001 (CJ|2)___ 600 Lanestar Blv.s., (Flant. 161) P.O..Box 10279, Sari Antonio, 49**9 Sharp street, Dallas, rexas lAp J&./7 n^v 8-77 lS)35*t9$ 9 77 ORIGINAL COPY i it's. P' <t,-v - ; . ' InVotce Nnmher Invoice Date PATINO HUIL.M' OK S'l/CIT. ACTHOKJTY COPY Vv. .^ ____ '-.. WORSMfiWS COMPENSATION \/" (17- 7 // f ^ V / Amottfli Do* Policy Number /V.*r. 0513 00 0)19031 00 F.nd. No 3`3 Named Tnttmtf sm! *<l<ires AMFRh i\N CAN lUMF'ANY (SEE El'iDORSf.MI NT a 1 ,2., AMLR1U\N LANE CRFENW!lull. CONNFC:ti CUT T Representative 2 SI'.O MARSH & MC LENNAN INC. A.ulit Period MONTHLY F Alpha Code AM ThU Fn?f mvyth k effective Policy Period: f rnm 'JL L.I2__ to 3 -7-3 (- 2 1 73 12:01 A. M.. and will terminate with the policy. utandard time at the address of the named iniurrd as stated herein. CHANCE IN HECLARAT IONS IT IS AGREED THAT THE SCHEDULE CONTAINED IN THE DECLARATIONS IS AMENDED AS FOLLOWS: SEE ATTACHED SCHEDULE FORM MUMPER lOOOf 16'V< BROADWAY PREMIUM !(.. ADJUSTED ON AUDIT Drw 'YORK , HI W YORK All other provision* and conditions remain unchanged. Issued hv EMPLOYS RS MCI CM. I.I ABILITY INSURANCE COMPANY OF WISCONSIN 1001 9 Srcrrlar\ President lA'Iliw Sci*tir* Co !.C T 3t T* Pm 0 JCir.J___ 'h'(_ R NY IriueH IKJ *mr T 5 2 72LR 2'fl I c PO, LA, SF,7C, PH, HAL,OL,A T,RF,I N^DES,KC.W,DC, TC, NOL, SL , WNJ, D^L, QHOU M. Bureau Copit. 1M> 4-66 C, SE , I N, K, SC, TF X, VA, NJ 315-62-4 ^ .^ .. (M) 15-200IE 11-55 S EMPLOYERS MUTUAL II I III! III INI III I )WATffflT| III III ILLINOIS EMPL'" YERS1 INSURAN^ OF 1633 Broadway, New York, NY 10019 AnDOjRi; "" ~ 'PMONEN0MfifR * IMMEDiATt niOR COVERAGE WAS IN f-f-FfG* FOR PERIOD FROM A.-?---11___________TO 2 1,78_________ _ through *ins coi Texas Employers Insurance , (NOT flEQUIftfO If HFHEWFO IN $AU COMPANY) Association policy NUMBEriWC*-Z*'34 399________ BELOW LISTPRINCIPALCOPPOnATFNAMEEIPST GIVING I'FApoUARTERS ADDRESS THEN US' EVERY SUB SIDIARY CORPORATION DOING BUSINESS IN TEXAS AND PROVIDE ITS PRINCIPAL TEXAS ADDRESS ALSO LIST EVERY OPERATING OR DIVISIONAL NAME USED IN TEXAS AND PROVIDE THEIR LOCATIONS CONTINUE l 1ST ON SEPARATE SHEET AND ATTACrt American Can Company American Lane............................ Greenwich, CT 06830 EMPLOYER SIGN HERE SIGNFO 'A /.L-_______, __ __ _____ -/ / ^_ ..i--77 "3... T1T1.C Of PFBr,ON ST>NI*", H<. i _____ date 4-. ' 7 7 7____ SIGNATURE HERE CONOffCfl E3 NOT ICE ON BEHALF OE EMPLOYER ` Locations: 2801 East Abram/ Ariington/~Texas (Plant 053) Clinton & Lockwood Drives, Houston, Texas 77001 T042T 600 Lonestar Blvd. (Plant 161)/P.O.Box 10279, ............. _ . _ ... San .Antonio, Texas 78210. __ ______________________ _____' .. ------- ---------- 4949--Sharp-Street r-Dallas-,--Texas---------- ------ - ------------------ A B Foim ?0-77 (R|v d 77) (S)3l*-?)96 9 77 ORIGINAL COPY *'M<J USA Notice of Cancellation of Compensation insurance INDUSTRIAL ACCIDENT BOARD P.O. Box 12757, Capitol Station AUSTIN, TEXAS 78/11 ^ '1 0 / The Industrial Accident Board is hereby given notice of the CANCELLATION OF A POLICY of insurance issued under the terms and provisions of the Texos Workers' Compensation Law, to EMPLOYER ADDRESS__ OCCUPATION . POLICY NUMBER American Can Company; MAT Chemicals, Inc. (Firm name under which business it conducted) American Lane, Greenwich, CT 06830 p'5 Ro O' Slreet Adduce) Cart (City. Stole Zip Code) (Character of business in which engaged) WC-1C-3L399 . POLICY PERIOD: eFrom 2-1-78 To.2' -1-79 DATE OF CANCELLATION 2-1-78 Flat 'Month and day' 19 , HOUR OF CANCELLATION.. 12:01 A.M. (Hour) (A.M. or P.M.) DATE NOTICE MAILED TO SUBSCRIBER INSURER__ Texas' EmPLOYens' insuRance Associanon {Fell nome ot msurooce company or association) ADDRESS BOX 275<5' DALLAS, TEXAS 75221 (P O Bor O' Street Addressj "(City. Stote Zip Code) Dated atDallas__________________ . Texas, this (Name of city or town) ,31st______ day of______ .January . ____ iMonlh) 19,,Z8_ This form must be executed by the CARRIER promptly upon the CANCELLATION OF A POLICY of insuronce under the terms ond provi sions of the Texas Workers' Law and mailed or delivered in person to the Industrial Accident Board, Austin, Texas. If an employer coases to be a subscriber either because his policy has expired or has been cancelled he shall on or before the date on which his policy expires give notice to his employees by posting notices to that effect in three public pl t>* around such subscriber s plant, and also to the Industrial Accident Board. I A t Form 9 IP#* 8 77) 1f!A 3031 f 18 77) ORIGINAL COPY TEXAS WORKERS' COMPENSATION ACT IjQ ~U~ NuHc* i hereby given by thr noDAH employer olid the named If urone# tnm^ny. a* required by the \KO^*Wokr, Compentofion Insurance Art, Chapter 103. Genera1 low*. 1917, onJ amendments thereto, (hot the named employe* W>* b*come o subscriber ond*r told Art ond amendments thereto and provided (or (he payment o( compensation to employees under tb^.tefmS'tiM provisions thereof. Any omgloyer or association willfully (oiling or refusing fa file this notice shall be liable (or and shall pdy to Ihe Stoto ol Tsxos a ponalty of not more thon One Thtwsund Dollars {$1,000' for eoch offense. INSURANCf COMPANY MGN HERt r>o >*o11nr r.wMie POLICY NUMBER:_____WC.-lCr34399 - (1 NEW POLICY XJ RENEWAL TEXAS EMPlOYtRS' INSURANCE ASSOCIATION haV'E qfcree;i7*awcT roii'rany oe asvocuti 59, PALIAS. TEXAS AWWl EFFECTIVE: FROM _2_rl-78______ TO_______ 2-1-79 -- OCCUPATION OF INSURED: ......................... .......... sir.Nfty SiGNATrihe HERE COITNSTITUTES NOTICE Ol. BEHALF INSUR^Ce COMPANY APPROXIMATE NUMBER , OF EMPLOYEES4 ,hS4_____________________________ ________ ESTIMATED ANNUAL PAYROU- ... 13x963J.9Q9_________ SCOPE OF COVERAGE X' ENTIRE STATE OF TEXA5 (All OPERATIONS) X PROPRIETOR AND/OR EXECUTIVE OFFICERS INCLUDED ^jtJwe NOTICE FOR DIVIDED RISK POLICIES COVERING SPECIFIC LOBS. OPERATIONS MUSI BE FILED ON I A B EORM IS4 REINSTATEMENT REVOKES CANCELLATION EFFECTIVE ...... EJTAEjp |OREIGN o BELOW LIST PRINCIPAL CORPORATE NAME FIRST. GIVING HEAD QUARTERS ADDRESS THEN LGT EVERY SUBSWAJTY CORPORATION DOING BUSINESS IN TEXAS AND PROVIDE ITS PRINCIPAL TEXAS ADDRESS. ALSO LIST EVERY OPERATING OR DIVISIONAL NAME USED IN TEXAS AND PROVIDE THEIR LOCATIONS CONTINUE LIST ON SEPARATE SHEET AND ATTACH American Con Company; M & T Chemicals, lie. * American Lane, Greenwich, CY06830 ~ i 0A1. " y<t~6<ri*vxr<,<,u<nr;HoiKi .. ! SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF I ClIDlAVfD | r ' dw..i-i8-;78_ t-A.t. form 50-77 (*y. | 77) TflA 5019-C [#-77| ORIGINAL COPY NOTICE THAT EMPLCn 418466 TEXAS WORKMEN'S COMPENSATION llESER EMPLOYER: fine lud* oil lrr> nor <t\ and complete motlmg oddreii. covered by ihn pohey under wKtch operotrvn ore conducted 'n I nvee Attach any e< twi> cndoMftwnh.^ . OX o ! 10< American nan Company; M & T Chemicals, Inc. ^ ----*5 , S , ADDRESS- _ American Lane, Greenvlch, CT 06830 LOCATION OF RISK: S ENTIPF STATE OF TFXAS DIVIDED RISK--EXPLAIN OPERATION COVERED BY THIS POLICY eOLtCY NUMCIR 1B-3I399 effective date 12 01 am 1-1-77 CANCCLLEO insurance. co. TEIA ^ ^ f j j NEW POLICY ] RENEWAL 0 EXPIRES AT 12:01 A.M. ON. JLslaja. APPROXIMATE NUMBER OF EMPLOYEES: O ago A. Stable Annual Employment:Ot-Z. B. Seasonal Employment by Month- mn .JIB, ________ MAS. , API IV n .All au5 ~T sLK 6d T~ nov peg _SaaJifg_ OCCUPATION ACT on BROKE* R^CELWIL Na**<e t$ hereby given by the nomed employet and the no*ned mywronce v mpony. o^|'<Q bf fie Texas rkmen s Compensation insurance Act, Chapter 103 Genera* lows 1^*7 and amendment* theret that the above named employer >os become a subscriber under said Act and amendments thereto ond provided for *se ooyment of compensation to employees under he terms and provisions thereof Any employe* o? ossocia*an vMlfvlly tailing or refuvag to fde this o^TOWS4N0USfTf#tt.'ho11 ay to the S*a*e of Texas a penohy I rv>* me >h^r, One Tt'..*-'4 p-tto's {*) 000j tor each flense' ACCIDENT BOARD EMPLOYER SIGN HERE SIGNED /^cC> > ''l/' - INSURANCE COMPANY SIGN HERE RBBSBHBBH TtTl E or PERSON SIGNING NOTICE TEXAS EMPLOYERS INSURANCE ASSOCIATION NAME OF INSURANCE COMPANY OR ASSOCIATION //BOX 2759. DALLAS, TEXAS f/ -- ADDRESS Jk*'' DATE _ .......................... SIGNATURE HERE CONiTHUTFS NOTICE GN SEHALF OF EMPLOYER Q NOTE RElVRri THIS NOTICE TO.- TEXAS EMPLOYERS INSURANCE ASSOCIATION DO SOT MAIL 7 0 INDUSTRIAL AC<tDENT* BOARD. 1 85 3a I-I2-77 $15.00 I A I Apptt*0 l#v I0l4t TflA 3p1JCII'*tJ ORIGINAL COPY TITLE OF PERSON SIGNING NOTICE SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY BECOME SUBSCRIBER8*8*** ti J W ^ ''' IEXAS WORKMEN'S COMPENSATION ACT Q PJ }}^~j EMPLOYER: (Include oft tar* mimt*. end crfeplet* moifinp o^drrm, <**i*d b> ?h*i polity under which opefcJi* or* conducted in 7#*o Attach orv necrunry wrfofjr*w*H ) s~t\ <$> Amoricon Gan Company; r4 & T Chemicals, Inc. t1- V? ADDRESS P' Bo:lc 27S9 DMIas> TX 75221 LOCATION OF RISK: 0 ENTIRE STATE OF TEXAS DIVIDED RISK--EXPLAIN OPERATION COVERED BY THIS POLICY POLICY NUMBER ErrCCTIVl OATE 1* 01 AM CANCELLCO INSURANCE CO WO-1A-34 399 NEW POLICY 1-1-76 TEIA t? RENEWAL B EXPIRES AT 12:01 A,M. ON_________1-1-7? APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:?5'j`L B. Seasonal Employment by Month: JAN. MA* am MAY ;tN >Ul au6 3TF-- --oTT n<5v DEC. OCCUPATION ACT. Off BROKE* Can Mfg; Notice s Hereby given by the nomed employer ord the named ir^L'Ooce corr,ysry, o* required by the Texos Workmen's CompenJotion Insurance Acl Chapter 1Q3. Genetol laws. 1917. and omendmer^ thereto, tbot the above named employer hos become o subscriber under $cd Act and amendments thereto and provided for the payment of compensation to employees under *he terms ond Drovinoo* thereof Any emolcyer or association w!Mly foiling or refusing o Me fhs notice shaM be liable tor and shall pay *o the Vote ol 1eos penouy of not more than One Thousand Damn's {j>' 000) for eoch offense EMPLOYER SIGN HERE j/1 - -^0* I INSURANCE COMPANY SIGN HERE SMSNEOu TEXAS EMPLOYERS INSURANCE ASSOCIATION KAMI OF INSURANCE COMPANY OR ASSOCIATION OT5^fcfc0TITLE C T PERSON SIGNING NO ^K^m. I , DALLAS, TEXAS 75221 ADDRESS A* DATE:. *#>*'*; A ISIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOyf^ Q NOTH: RETURN THIS NOTICE TO: . TEXAS EMPLOYERS INSURANCE ASSOCIATK)N/VS{Jr> DO NOT N'T.BOARD. MAIL TO INDUSTRIAL ACC!DfcAT^iiyCf G TITLE OF PERSON SIGNING NOTICE SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY tTAtlA.t,5A01yJpDr(nIMriFIt)s I0l4t 85 at 12-24-75 $15.00 ORIGINAL COPY Insurance 35236 No. COPY Knd,>r*<*ni<*t No,.. 6 B02X3521 NAME CHANGE ENDORSEMENT It .Is agreed that the Name of the Insured in Item 1 of the Declarations of the Policy is hereby amended to read: American Can Company; M & T Chemicals, Inc. This endorsement shall hr subject to all of the terms, provisions and eruditions of the Policy, and nothing heroin contained shall vary, alter or extend any term, provision or condition of the Policy except as herein specifically stated. This endorsement . wHon siirncd hy a duly Authomrd Representative of the Company shall form a part of roiic > ~'n i * m p f p *" ~c rnTiFicATr. TiUMBC ' * Issued "ev "The~~ z-34399 rexas smPLOYens* insuRance Associanan of Dallas, Texas TO ' American Can Conpany AND fHAlUBF rrVf CTJVF ON^cTtV February 1, 1975 suTneu a- .............. '** Dallas, Texas 85-4204 jib/5-19-75 at the same hour of said date e* the hour of day provided by the Policy for commence* ment of_the Policy Period, and this endorsement shall terminate with the Policy. by" ** ~ .. .........................~ ~ AUTHOR)ZEO RgrRESCNTATIVK Additional IAB Fee - $7.50 NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER _ Bi)U>13S9 TEXAS WORKMEN'S COMPENSATION ACT | |/ EMPLOYER: ln< fctd** H lrm ncmet. n* f compUte moJmg odd.#11, cov*r*d by tWTpe!.y u*def whtch oppfnton, o* uxxWi^d n Texov Attoeb ony rtecpiinry frtfioYPPmwih.) American Can Company / ADDRESS:______A__merican Lone, Greenwich, CT 06330 LOCATION OF RISK- ^ENTIRE STATE OF TEXAS DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY POLICY NUMBER Z-3h399 effective oats i* o* am 1-1-75 CANCELIFP NEW POLICY & RENEWAL & EXPIRES AT 17:01 A.M. ON____1-1-76 TEIA APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment: B. Seasonal Employment by Month __ JAN_ m MAff APR may tut 7~~1T _7AuUcOT._~-p.SST ~~7xX NOV. otc. Can MfV. ACT OH BROKER Aoonrss Notice is Hereby g-vpn by the r-o*red mp'nyp' and the named mturonce compony. os required by, the T*os Workmens Compensotion Insurance Ac* Chop'* 103 General lows ond omondrnonis thereto, that the above named employ*' '`os become o subscriber oodei 5o-d Ac* end o'-npndn'e-''* `Hereto and p*ov*ded for the payment of compensation to employees and*" *> terms ond provisions 'her';.* A'V emplc><.* /* oamv' o'l.ja wlfuU' fpihng or refusing to Me this nct-re shall be hoble for and shall pay to the Stote of Texas o peno!*y ro mo'** >*vm 0*-p *qv4 Dollops (51 000) for each offense EMPLOYER SIGN HERE INSURANT* COMPANY SIGN HERE SIGNED. TEXAS EMPLOYERS INSURANCE ASSOCIATION NAME OF INSURANCE COMPANY OR ASSOCtAliGN T'TLE or f>CRSO*9KMltN& NQYU.* . A*L.Ou*El* r BO^HLt DATE . BEHaTt Jf Wko?ei SIGNATURE HERE CONSTITUTES NOTICE ON SIGNED:. BOX 2759. DALLAS. TEXAS 75221 ADDRESS NOTE: KKU-RN THIS NOTICE SQci l=>AMrC D '-P^3 TEXAS EMPLOYERS INSURANCE A9o?TOfiVlM^C` VO NOT MAIL TO INDUSTRIAL ACCIDENT BOARD. TITLt OF FCRSOH SIGNING NOTICE SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY t A I. Apprmd l*v ID 1 49 TftA 30130(110) 85 07.50 nr 32/17M ORIGINAL COPY losiiriinro ('onurmsinn No. 35SJJS E>t!ntAPm**nt No Tha L*r*f.icn*i of Operatione it tfc* Lfctr Ifcrt f Its* #1 of the 0*oiMtljK>e or tho Policy to which this satarsKMot is sttsehed sJsfcll r**d Arlington Wrt, 2601 B**t Abram Stnwt, Arlington, t***s Hecutoa JFlent, is*taraod & Clinton Qpivo*, Hmston, Xuta* aa Anisaio P. 0. Boot 10350 BMftbssvjr Station, 9m Antonie, Tesws Csnoalicfctaril Sals* Office, (fcilt* 530 feetonga Bank A %nt Tswkt, Rnsbane* Itekf Bkllna, T*x*n Butterink, 306 Cole Bferoat, fella*, Ttasus Unique *lpar Bltribu< ing tenrleo, S5Q3 lady Bird Ian, ?. 0, Box 20933, Cello*, Vows 73920 This endorsement "hn 11 lie subject to nil nf the terms, provisions and renditions of the Policy. and nothin); heroin contained shall vary, nltet nr extend any term, provision or eonditinn nf the Policy except ns herein specifically fllnted. Thin emlomemenl. when signed hy a duly Authorized lleprexentative of the Company shall form a pint of POLICY n L f BT it It AM NIIMBFR I^IIU/ BY TME ' ' ~ S>3*399 TO JBX0B EmPLOYBHB' inSUWanCB ASSOCiarion of Dallas, Texas Aawriesa Q*n anp `.maii. nt r rec7 `\.T 1975 .r.**r at the same hour of said date as the hour of day provided hy the Police for commence ment r,f the Policy Period, and thiaendoTsement shall terminate with the Policy. 7~ey . - . - ........... -- * Dnllns, Texas I AUTHORIZED RCRRMCNTATtVt m* mn> FORM 0 TV J.2 EXtCUTIVE OFFICERS, PARTNERS AND SOLS PROPRIETORS ENDORSEMENT - TEXAS It in a greed ih u. 1. >nch insurantc* is is afforded by rhc puluy by reason of the* designation of Texas ns lino \ ./ rbr ations dors not .ipplv to mmrv, tnclu.ling dcuth resulting therefrom. siiMaiMod In smv c\rt v'i* e officer, partner or sole proprietor of the insured, except such, if nv. as are designated brio* n' in hem i of the ileclarations. "RcmnnrMitofi." when used as a premium bash, for such insuranc e, shall not nu huh* th<* remuneration of anv executive officer, partner or sole* proprietor of the insured not so designated. All n tin- . <i t utive officer Designation of Persons TMs endorsement shall be subject to all of the terms, provisions and conditions of the Policy, and nothing herein contained shall vary, alter or extend any term* pro vision ot condition of the Policy except as herein specifically stated. This endorsement, when signed by a duly Authored Repiesrntalive ot the Company shall form a part of Dallas, Texas 1 l>A I 7.` if A <J.* .tar"' ^yct ottH at the same hour ol said date as the hour ot day provided by the Policy lot commence-) men! ot the Policy Period, and this endorsement shall terminate with the Policy. , v P*# r.s-aPUjfV^-*- AUTHORIZED REPRESENTATIVE If AM 'WOR*MKN* COMPtNSATION ACT EMPIOYER: (Include tffl In'** noTr/*v ond complete *miil*nq tKkrtnn crrvernd by this polky under *Mch otwcrtif.m Ore ccv^duCMd v rvllW'y endfuiemnnh ) __ Meri.cfm.5aQ .Ccmpauy:................ I ony ADDRESS- .... African Lane* jQreenwleh.CT 0683? lOCAflON OF RISK: TJ ENTIRE STATE OF TEXAS DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY f ~ _ POUCY NUMBER EFFECTIVE DATE 2:0t AM CANCELLED INSURANCE CO Y-34399 NEW POLICY 1-1-74 GJ RENEWAL FXPIRES AT 12:0) A.M. ON TEIA A/ -7-^r APPROXIMATE NUMBER Of EMPLOYEES: A. Sloblp Annuo) Employment:____ 2Q53 B. Seasonal Employment by Month: JAN...... __r.ee,.... ___ MAR APR. MAY JUf4 JUt _AUG SEP. __ oUZZ ___nov_. Can Mfg. OCCUPATION*'-*' AGT OR BROKER ADORESS CITY STATE ZIP Notice n hereby' given bv the named employer and the named mi.ironce company, os required by the Texas Workmen's Compensation Insurance Aft Chapter 103, Gonerol laws J917 and ainendn>er* thereto, that the above named employer has become a subscriber under said Act and amendments thereto and piovrded lor the payment of compensation to employees under the terms and prov-sions thereof Any employer c> ov>ocotor* wilfully railing or refusing ; > file this notice shod be liable fo* and shall pay to the Stole of Texas o penalty a* 'o* more than One Thousand Dollar*' 'SI.000) for each offense ft EMPLOYER ijiGN HERE* 'Am i SIGNED. DATE:. TITl Of PERSON SIGNING NOTICE JNDUj SIGNATURE HERE CDNSTHimS NOTICE ON BtHAll OF EMPLOYER NOTE- Kin VPN THIS NOTICE TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION DO Nor MAI I T HOARD. i INSURANCE COMPANY SIGN HERE TEXAS EMPLOYERS INSURANCE ASSOCIATION RANCE COMPANY OR ASSOCIATION 2759. DALLAS. TEXAS 752i ss rARO TIITTULSE OP PERSON SIGNING NOTICE JURE HERE CONSTITUTES NOTICE NAIF OF INSURANCE COMPANY I A I App<evd l 10149 UlA 30130 <11 ead 12,/7/8, 85 $7-50 RIGINAL COPY NOTICE THAT EMPLOTCK KA3 BSC Tber TEXAS WORKMEN'S COMTOttATION ACT iffA y//*? EMPLOYER: (Jr>t Wp nit |>tin nnrnn, o* * co*>tp\*h oyoiU'Q ockfrett. covered by ifiH pokey under whvh optotiom or* to*>iucf.d m T**ai Attorh any nwc*Huy <nffoi'r>mti ________ Amic^_raJ3.<saE5' .JLocteyo{l.&,,Cllnt(mJteiY93^_itouiton,_Jteui. xmsem. ^AmgTtaMi^c^nrrQH^Ml^g^^ San *ntsnip, Pallas, aexas LOCATION Or RISK: E ENTIRE STATE OF TEXAS DIVIDED RISK--EXPLAIN OPERATION COVERED BY THIS POLICY eottCY NUMBER X-34399 NEW POLICY . & RENEWAL crrtcTivc date trot am CANCELLED 1-1-73 ffi EXPIRES AT 12:01 A.M. ON. INSURANCE CO. 5EIA 1-1-74 APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:____________ B. Seasonal Employment by Month: JAN ...IF...... MA$ . AP* --MAY 2053 JtjN JUI AUG ~UV 6Cf 1 NOV SFg~ OCCUPATION Can Mfp;. f GT Oft BROKER Notice hereby given by !he named employer and the named msu'ance company, as required by the Texas Workmen's Compensation In^u'cv'ce Act. Chopter 103. General Laws. 1917. and amendments thereto, that tho above named employer has become o subscriber under said Act and amendments thereto and provided tor the payment of compensation to employees under the terms and provisions thereof Any employer or o'^ot-ionon wlfully fading or refusing to file this notice snail be liable for and shall pay to the State c* Texas o penalty of not more than ''Ve thousand Dolors (SI.000} for each oftense EMPtOYER SIGN HERE INSURANCE COMPANY SIGN HERE L/IJ JS.GHE0 v * TtTtF or PERSON SIGNING NOTICE DATE SIGNATURE HIRE CONSTITUTES NOTICE ON BEE TEXAS EMPLOYERS INSURANCE ASSOCIATION NAMp^r INSURANCE COMPANY OR ASSOCIATION BOX 2759, DALLAS. TEXAV705 ----'t/-- -- h J--s- / s: AOOflESS /if 1 SfSKtO:_ _ _ _ NOTE: RETURN THIS NOTICE TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION ,1 DO NOT MAIL TO INDUSTRIAL ACCIDENTJON BOARD. ' 73 or PERSON SIGNING NOTICE SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY -tfiteoifA 12-l4-72/al 02 NAD $7.50 Ncedept. l.A.1. Appfe**d 10 1 4e TIM 10D-0 (>**) ORIGINAL COPY lockwood & Clinton Drives, Houston. Texas_______________ __________ xcxsmx Antonio.,. DallasJl_Xesaa......... ... LOCATION or RISK- fX ENTIRE. STATE OE TEXAS DIVIDED RISK-FXPIAIN OPERATION COVERED BY THIS POLICY POIICV NUMpr^ W-34399 NEW POLICY crrecTivF date u-w am CANCELLED RENEWAL 1 EXPIRES AT 12:01 AM. ON l-i-73 INSURANCE CO XEIA APPROXIMATE NUMBER OF EMPLOYEESA. Stable Annual Employment:z B, Seasonal Employment by Month: IAN ,, f c.?,__ MAR APR MAY f IUN JUI. ~ AUG. SEP. cxIt. NOV 0id ' occupation ___ Can Mfg. ACT OP BBOKFP ' AOOPFSS CITY STATE " ZIP* Notice n hereby given by the nomed employer ond the named Muuronco compony, os roquirerl by the Texos Workmen's Compensation Insurance Act Chapter 103 General lows. 19P ond amendments thereto, that the obov named employer hos become a subscriber under *aid Art ond amendment* thereto ond provided lo the poyment ol compensation to employees under the term-, ond p'uvisrors thereof Any employer or association wilfully lading or refusing o file this notice shall be hobfe lor and shall pay the $.>*> v*1 Texas a penalty of no* more than One Thrr-.ond Dnlln'*, ($1,000) lor each oflense. l EMPLOYER 51GN HERE i Y<\ (SIGNED___ W-W- s-Ll* <J_ IITI.F OF PTRAON SIGNING NOTICE DATE'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER NOTE: RliTVRN THIS SO'IIU.TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION DO SOT MAIL la ISPt'SI RIAL ACCIDENT BOARD. INSURANCE COMPANY SIGN HERE TEXAS EMPLOYERS INSURANCE ASSOCIATION MAMJ or INSURANCE COMPANY OR ASSOC `41 ION '7 - BOX 2759, DALLAS, TEXAS 7522>' *** AonttrsF SlGhty;^ Lc^TR' SIGNING NOTICE SIGNATURE HERE CCOOTNSIIT ON BEHALF NOTICE ANY 2/al 02 iti 10 l if $7.50 ORIGINAL copy Comm.#35216 Copy EXECUTIVE OFFICERS ENDORSEMENT - TEXAS Vi~3.i (MM"I I: is asrrfd that: 1. The insured being a corporation, such insurance ns is afforded by the policy by reason of the designation of Texas in Item * of the declarations ones not apply to injury, including death resulting therefrom, sustained by any executi 'e officer of the insured, except such officers, if any, as are designated below or in Item 4 of the declarations. 2. '"Remuneration," when used as a premium basis for such insurance, shall not include the remuneration of anv executive officer of the insured nor so designated. All active executive officers Designation of Officers TMs endotsemenl shaft tie subject to all ol the term, provisions and conditions of the Policy, and nothlni herein contained shall vary, altat w (stand ny tofti, pre vision oi condition ol the Policy fucept as herein specifically stated. This endorsement, when sijned by e duly Authorized Representative ol the Company shall torn a part of POLICY NUMBER ~~ "" --------..................... ...................................................... -- W-34399 TO issued by the TEXAS EMPLOYERS' lHSURAHCE ASSOCIATION ol Dalits, Texas American Can Company AND SHALL BE EFFECTIVE ON Idult) January 1, 1972______ SIGNED AT Dallas, Texas =uL*jL&22__ _l--j_ TE'* *?. _C1 inton.Drive,.JIpu_atqn, Texas__________________________________________________ JSOOBOK- _Additional..Location:__&rlio*con^_SanLAntonio_andJftallas*_Xexaa. LOCATION OF RISK: ft ENTIRE STATE OF TEXAS DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY POUCY NUMBER V-34399 NEW POLICY f3 RENEWAL eFFiCTlVC OATE IJiOl AM CANCCLLCO INSURANCr CO 1-1-71 TEIA 0 EXPIRES AT 12:01 A.M. ON 1-1-72 APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:2*05.3__________ B, Seasonal Employment by Month: JAN ftS. WAR APR MAY JUN JUl. AUG. iEP nO NOV. 0EC. OCCUPATION .Can.Mfg* act on unoKCft Nonce is hereby quen by the named employe' and the named insurance company, os required by the Texas Workmen s Compensation Insurance Ac* Chapter *03. General law*. 1?! 7. and amendments thereto, thot the obove named employer has become a subscriber undo* sord A< and amendment* pod provided lor the payinent of compensation to employees under the terms and provisions thereof Any employer or association wilfully lading or refusing to file his notice shall be Itoble lor ano s'*o!l poy to the S*o!e oi Texas o p*nohy o' not more than One Thousand OoMo's ($1,000) lor each offense. iai -- 1'M iuw> -- w II -- II-- > T7' SIGNFD- .... L J. J , *V . - p i CJ . Title of PFRSON SIGNING NOTICE oatf . . SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER NOTE: RETURN THIS NOTICE TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION DO NOT MAH. TO INDUSTRIAL ACCIDENT HOARD. INSURANCE COMPANY SIGN HERE MBWBKBfH TEXAS EMPLOYERS INSURANCE ASSOCIATION NAME OF^JJ^SUJTANCE COMPANY Oft ASSOCIATION / prfx 2759. DALLAS, TEXAS 75 *- APOftl-SS ,,* Yl SIGNPF) / ' -'->"^7'^' -- d \R ^ T- i ---------------------- j----------------- TfrLt or PERSON SIGNING NOTICE SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF Or.INSURANCE COMPANY 4 I A | Ap|UOv#4 Itr 10 I if itu son nm at) ORIGINAL COPY gggryj Insurance f'ommission No 'J^ , ffih* Otm- af tfee WB&x&mr Is afiwtwSeS to c*tsi tumrlom Con CwDfiay \ Item X or t3te palicjr Knflftj Hi`T.rr,{ Un. Cd. >';S ^TcHe TV %I670 L ^sjgwsTfW: Thi; endorsement shall ho snhj/ci to nil of the terms, provisions and conditions of the Policy, nn!^t&lf9mmmLt^IrTahal^vary niter or extend any term, provision or condition of the Policy except ns heroin specifically stated. Ihii endorsement, when signed hy a duly Authorized Representative of the CV lpnny shall form a part of nouo rii/Mpm *-3*3*9 (.fprira Atr numsix G-3^399 TO ............... ~ ................................. .. ssufo nv me Texas smpuoYens* insuRance Associanon of Dallas, Tews tesati&m dm Company and inin n* f r/ccnvF om'*rs' r tevmsr? 1, 1970 SiGMCD #'. ' ' " at the same hour of said date as the hour of day provided by the Policy for commencement 'tf the Policy Period, and this endorsement shall terminate with the Policy. ~ by ' ' " ............" ~ 1 hdlns, Texas 3-io oe-oo AUTHORirCO RCRRWCNTATIVt i- _____ POLICY NUMBER _ EFFECTIVE DATE 12*01 AM CANCELLED j INSURANCE CO. ___ TJ-3U399 .................... _____ NEW POLICY ] RENFWAL _l;l-7............ .................... .. i EXPIRES AT 12:01 A.M. ON. 1-1-71 TEIA APPROXIMATE NUM8ER OF EMPLOYEES: A Stable Annual Employmanl: B. Seasonal Employment liy Month: JAN, J FB. WAR | APR, MAY JUN. JUl. AUG SEP. oc NOV. DEC, J ________ I occupation ,,_Can_Mfg._____ ACT OR BROKER ` ' ................................. ........................................................ - AOPRFSs" " CITY "" "" gTATE ......... jTp" Notice Is hereby given by the named employer and the named Insurance company, as required by the Ta If Chapter 103, General laws. 1917. and amendments thereto, that the aoove named employer has bccof uUSOitW uAB>r tal'JfAcPkndM'nrl t'jtjoto and provided for the payment of compensation to employees under the terms and p'j idions thereof. Any employer or associafcn ml/ully failing or refusing to file this notice shall be liable lor and stall pay to rhe Slate ol Texas a d ial|y of not more Itan One Thousand Dows 1JI.000! for each offense. EMPLOYER SIGN HERE LU SIGHED-. w- 7T1F. OK PFRSON SIGNING NOTICC date- ,, . .... ............................................. ............. SIGNATURF HFRF CONSTITUTES NOTICE ON PEHAtF 0T EMPLOYER NOTH: RETURN THIS NOTICE TOTEXAS EMPLOYERS INSURANCE ASSOCIATION IX? NOT MAIL TO INDUSTRIAL ACCIDENT BOARD, INSURANCE COMPA TEXAS EMPLOYERS INSUMNCE ASSOCIATION NAMf or irjjfw^NCE COMPANY on association r8(W/?753. Dallas, Tews 75221 SIGNED: ' ^ v /'--* (._ TITLE OF PERSON SICNINC NOTSCE SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY I A yir ' 49 f m 9049 Co- p- O. Bo> 9795 Amlin. Tun. Jllil ORIGINAL COPY ( * Additional Loontio-.;: 7/17 Arlington Plant, 2801 East Abrams Street, Arlington, Texas Houston, Plant, Lockvorel & Clinton Drives, Houston, Texas San Antonio riant, P. 0. Box 10150 Hackberry Station San Antcnto, Texas Consolidated Sales Office, Suite 53 Exchange Bank Trust Toper, Exchange Park, Dallas, Texas Bolterick, 302 Cole Street, Dallas, Tcxas Unique Zipper Distributing Service , 2983 lady Bird Lane, P. 0. Box 33 Dallas, Texas 75220 1C urm * Miifitir* t V,. 35816 Ftvdor**.\*rt Sfi Xtw Show r tb Xqpiegmr lo Xtm #1 cf the fleelaratioa of the Palicy to vhieh thi* ccasrcessart la attaebad la aaefetert te r*4; American Cea Ccetpntxy & Buttcriek, A Dlriaion of Asartctfwv Cwa Coa^oay * Unique Zipper Distributing; Service of Buttcrick, A Mvlnien f American Can Cwapany. Zt la further agreed that Katorwneat is amended to include the follcwing: - Xoestian of Operatic* - Unique Zipper Distributing Service - 2983 Lady Bird beau P, 0. Bo* 20933, Delia*, Ttxas 75220. R EC f TIiik endorsotnpnt .'hull hi* J*nlji*n to jit) f the forms, provisions ni conditions of the Police. nod nothing herein contained shall vary, ' ,,r *M<,nd any trim, pmviM.ui or condition of thn Policy <*\rrpl mu' herein ^ovrifirnll.N Hinf'! *K This PMilnrsintionl, when *dvlW'd hy :i dulj A uthoi r/od f(opn><x>ntnMi?'c of (he (Ttnipnny shut! fmin it port of rj>LK ` NuMnrn i rin aii tutMPtn m^irn by thi T-3^399___ Texas EmPLOYBBB1 insunance Asaocianon 0f Db11, thm Americas Can Coa^esy AMn nt nrrr7). on .o'*-**. ' * " Au&uat 29, 1969 ~ at the same hour of said date as the hour of day provided by tha Polity for tommtnco* mont of tht ^Poliry Perind.and this.endorsement shall terminate with the Policy. ("by* " "* Ii/iHns. Texas 9-8"69 02-00 ______ , MiYMOftlZKD ftBPRKSKNTATtV* IriHrimr.'f rnnsw'ist'-.n pitcher* "'v.+fnt Kn-,. b It & gw** tant Vm Immttom la ml H. 3, to life* policy to neiltfb 0ii oe&wtaauwtt fa **t*wH*4, or ters% meaM - to read aa follow* Ayltngtoa Plaat, sSea, Sbat JOwanw aftxatwfc, AyUdgtea, Sum Kouaton n*nt, i&toamon a cHb*s ttnwif Smetaa, fmm m*s Aatonlo Flanfc, 2*. 0. Max UCEL50 tecttbarry Statloo, 3* Aatcwie, 9mm Caasolidafead Mi GfCIc*, Salta 530 Wtrlwni Saak a treat 9atar 'fyg^tagr PAfek, Steeas Bntterlrit, ?02 Colo Sfcra*t, Salliwi, *au :-!; ..; j | Hi- r-mlnwpinpn! shnll ho subject to nil of the terms, provisions mm! condition* nf the Policy, and nothing )nwouVTmr*4*J<H Shull vary. nher 01 rvtend nn> term, provision 01 omul lion of the J'ohry except n herein specifically stntcil. This endorsement, when M^ned by jt fluty Authorised Keprosentstivc of the Cnmpnn> shall form n part of 1`OUCV NjMB! cmiiMGAtf NiiMprn ir*bWfO B> THF ................ Texas EmPLOYBRS' insurance ABBocianrn of dHm. t** .teaerietto Cam Ctwjamy AMr>- SshHaAiILl RRCe rrFefctCtoTIV? Qir.nan momtry 1, S'GrVFP ai h~30. Hnllns. 'i exfls 0040 Tf A ** at the Fame hour of said date a* the hour of day provided by the Policy for eommanc*- _mrnt of the Policy Period, and thli endorftempnt ahatl terminate with the Policy, ~*1 "by" " ' ...................... ...............................~ ~~~ AUTHORIZE ACeaOICNTATIV* *&fi a 7 mm or rMriow! NOTXE THAT EMPLOYER HAS BECOME SUBSCRIBER tfW tVOKKAirFM COMPENSATION ATT s.1! &fm mmN^ mwurf frr tM* nft/lc' t mj,t~ A *fst* rwr**fi Vn i^ttfan* an vWw^mI in TnM eit?!**# Tku t American Can Comj>any A PutterInk A Division of American Can Company P. 0. Box TWO Hackberry Station, Dan Antonio, Texas ADDITIONAL LOCATIONS: Arlington, Port Worth, Dallas, Texas i. m lo ll U) fviiV iKrigp tfvaM' i;:o!.;siR!Ai. . M.0 0 NfW POLICY T-34399 ^3 RENEWAL OF POLICY 3.31*399 EFFECTIVE AT 12:01 AM. ON 1-1-69 EXPIRES AT 12.01 AV. ON 1-1- [U l0OTI0N0rm- HrmiRF STATE or TEXAS I__ I If rfivsdpd i*sV pivc operation cowed by ibis policy APPROXIMATE NUMBER OF EMPLOYEES A TALC ANNUAL fMPLOVMINT_____ 2,053 * SCABONAL CMPLOYMCNT.tv MONTH FANDAAY Ar^rtuftr I rrnR iary rc; iiPAno** . Canjifg. AOfNf t> ______________ _ no ft BTKiit MARCH py t t Mr Notice is hereby given by the named employer end the named insurance company, ns 1 -`Cipr'-d by the Texes rVorlmen`* Compensation insurance 1 .'''jpi.j 103 General Lams. 1917 and amendments Ihereto. that the above named employer has become a sobscr.nrr under said Act and amendments thereto and provided -'1 the payment ct com pensation to employers under Ihp (arms and provisions thereof, Any employer or association wilfully failing of refusing to file this notice sorb "r *- rof shall pa, tn the State ol Imps a r'-nait. 0! pot mni than One Thousand Dollars (It.OtV.) lor each al'ri.ir IMPIOitf -ll'-s ilJFI ! >' SIGNfP ^ <J vO^ TTt* 0* nAION IONtNfl *..incf DATE-_______ ____ ____ _____________________ , . _________ SIGNATURE HERE CONSTITUTES NOTICE ON BEHAI F Of EMPLOYER Nii Kin a*v jitis vo7/</ n>tr\t\ivn n t k\ I*. SI H-\St I IVYS no \ot Amu jo tsuvriKi.u ujjjv s 1 rO"B 1A 0- irORMtRLV 20.1 INSURANCE COMPANY S!0* UlPf _ TEXAS EWPl DYERS* INSURANCE ASSOCIATION NAmK or INIUdASi,! I'OMfANT OR A*t0 a *T >Op ?2?59_____ 0AtLATx TrKAS 7&2\ AOOftt* SIGNED'. _ _ ^UNDERWRITER Tfflt of r**<* tstna noi>. i SIGNATURE HERE CONSTITUTES NOTICE QH BEHAU 0* INSURANCE COWWW Comr. // 3>JMb EXECUTIVE OFFICERS ENDORSEMENT - TEXAS !\-U fV 1 ,V#> ?) lr i*. ugrr ed that: l. I'hi* iMirrd bring n cirporsi!ion, s'lih inMimncc ns is afforded by the polity bv rru-'on of rhr designation of IVxns m Item * of the dr? lurmioir* linos not. .ipplv to injury* including death resulting there from,-- * Mtsramed bv ativ executive officer oi the injured, except such officers, if nnv, ns ,u<* dr<>j>nnred below or in Item A of the dn lsunt ions. "Remuneration," uhrn n*.rd ns . prrimttm basis for such msm.tm t*, shiill not mm bub* the remuneration of uiv e\tiiitive cdliiri of the insured mf so designated. All active executive nffn < rs Pcsignjation rif Officers 1 I | | y )pt rrv. 1 - '!M ; This endorsement shall be rubjpct In all of the tems4 provisions and conditions of foe Follcy, and nolhlnj herein contained shall vary alter ot eitend any term. pro- vi<lp nr cnn/fiti/m of the Policy except as herein specifically stated. This >ndot$emrftt, when sijned by a duty Authored Representative of the Company shall form a part of poucy'nI'muer "" ' "' T~3*39v Hiucit by IV TfXAS EMPlOVERS' INSURASCt i'lOCIATiOHjl -- American Can Company V 0. Box 7008, !t:ck.berry Station, San Antonio, Texa-. A NO SMALL fF F t*'f CTIVE ONMVl* January* .1^ i-UX^V "' ............... ~' ' at (he same hour of sad date as the boi>> of ite* pnv-vw t* *** Pc'*cy tot cos#nce* ' mjrt o' !> Policy Period, and this eniaoea**: sH* w*ts in* Policy. SIGNED AT Dollns, Terris fnsmnnre < mnmcion No Endorsement No $b Wmm T Vtm Ma&am* 4 Hm & w jMlmUm r fta a&fesar %* MfelA ** MiBiwiil t .iftiwrtwi t* tmwlv imM ta vm& a* frmamt Awwibmm am ctMmr a ttmrnrtm a atMo* r Hwrinit aw etwfwsy REc-d poor qualm Thi endorsement >dall hr cubjeei t* nil of loo terms, provisions ami conditions of the Policy, and nothing heroin contained shall "ary, niter -r any torm, provision i * oiulij;mii of the Policy except hs herein specifically slated. This o,i.|.i onient, when signed by a dnlv Authorized Represent alive of the (`ompnny shall form a part of rOt U CfOMMCAfV numbfo j*m;ed by the ' * Texas EmPLOYeRB' insurance ABSOClBTlon of DftUu, Texas . , AKKtxm am amo CHAU nr it tx 'ivr on i** * $mms % is <n,en a* lWlb*- 'I ''n< TST at the same hour of said date hv the hour of day provided lv the Policy for commence, men! of the Policy Penial, and this endorsement shall terminate with Uu# Pobcy. i ov ADTHOHuto a&eaeaKNi ATivt 356 Knd'o: mrtd M' US' *mn of Uit Espli^tr la Hot #1 of the Di2antl of tt PttUjf to iAIA thl* waaonwfOTat la afttoefc* it mmaaAaA to rawit tewtott On Camfmcr act toHarlck CtMpaay, A Olirlttm of Astaricasa Can Cm&mqr 'Hijv |. t w nii.it he Mt'n. 11 in nil of the terms, provision** and conditions of the Polic.v, nnd nothing heroin contained hall vary. nll-l or extend any loni, pn>vv*in o* monition of t>' Policy except s heiein speoifioally slated. Thi*. end im meat, h*n <mnod Ky dvdv Anthiomd Pepresmtalive of the Company .shall form n patt of l . .1 k AM NirMtU i? <K3*39y S-3&399 Texas EmPLOYeRS1 insunance Associanon of imiins. to tMirtMB On Carn^mg and > jii r.f r1 s Tiv r ;* Jaranry 19. 1965 at the same hour f Mini date ns the hour of day provided by the Pnticj f *r commence* meat of the PolieytiVrmd, nod this endorsement 'hall terminate with '* Policy *Mh.v *! * Al.THOPlZCP areBCSENTATlVf NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER TEXAS **ORXM:M,$ COMPENSATION ACT NAME Of WlOYfR flnffad* #i: fit* n*PH**i, r*rt+4 hr thf polier oitd*r whit-h npmintion *r comfoein Tvim, A na*p/^|v frtM Mi>Sn( adrtr+ma / American Can Company P. 0. Pox 7008 Horio-i'i-i v !St,ntion Snn Antonio, Texas DEC 1 1967 TEXA3 INDUSTRIAL ACCIDENT BOAaD ADDITIONAL LOCATIONS: Houston, Texas Arlington, Texas Fort Worth. Texas Dallas, Texas u NfWPOllCY fxl renewal of policy -... . N0:Q-3*399.. LOCATION or RISK L?J ENTIRE STATE. OF 1EXAS If divided risk, give operation covered by this policy ocr\B*T ion ____Can-HEg,_____ AGFNT 0*9 nr?0*T tnmivt at i?di a.m. on ________ 1=1-68 NUMBER OF EMPLOYEES _________ 2*053 EXPIRES AT 1?:01 A, U. OH _l=jl=6q_ ESTIMATED ANNUAL PAYROLL $6,160,000.00 Notice is hereby given by the named employer and the nam'd insurance company, as requited by the Tern Woikmei.'s Coirpensatirv Insurance Act, Chaplet 103, General Laws, 1917, and amend rnents theMo, that the ahoy* named emoloyer has hrconp a subscriber under said Act and amendments thereto and pro.'ned for ine payment of compensation to emplovees under the lerw and provisions thereof. INSURANCE COMFANY SluN HERE TEXAS EMPLOYERS' INSURANCE ASSOCIATION NAME OF INSUMANCt: COM*****'* OH ASSOCI A* i>S P. 0. BOX 2759 DALLAS 21, TEXAS AOOESb FOA* IA n-U (fNMilr 1U) .......................................... jjNBEsyuny?. TITLE OF PFiTWv .......... ........... SIGNATURE HERE CONSTiniUS NOTICE ON OF HAL f Of INSURANCE (WANT