Document b8R1X60Yb5a24n7eVQ6Dwb80
LEONARD W. RILEY, JR, EXECUTIVE DIRECTOR
TAMPERING WITH THIS LABEL NULLIFIES TKE-SERTIFICATION
TEXAS WORKERS' COMPENSATION COMMISSION
SOUT HFIELD BUILDING, MS-96,4000 SOUTH IH-35, AUSTIN, TEXAS 78704-7491 (512) 448-7900
STATE OF TEXAS COUNTY OF TRAVIS
CERTIFICATION OF SPECIFIED INSTRUMENTfS)
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 IAB 20(Notice that Employer has become Subscriber) from 06-01-68 to 06-01-79 for:
Mountain States Telephone & Telegraph Co
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 30th 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
1 ploucv Kummm
IFFICTIVI OATI IMt AM
CANCCLLZO
1-59m
V NEW POLICY
6-1-77
B RENEWAL
H EXPIRES AT 12:05 A.M. on 6-1-7$
-----mu
----- 1
!
! APPROXIMATE NUMBER OF EMPLOYEES:
| A. Stable Annual Empioymni:__^Z---------------___--
-------- TEX.U-4N0USTRIAE:-
":i B. Seasonal Employment by Month:
80ARD
; f jan !1 1
|MAR. Aft, MAY JUN. JUL i AUG, Jro 2z 77i r
|1
. Telepbor Talegrssph Co.
IhKf IDAKlflP
0^CU^TW^
-------------------------- ----------- __.------
rQw.
agt. on *rokir
aoorcss
city
' #tati
sm
Notice hereby given by the named employer and the named insurance company, as required by the Texas Workmen s Compensation Insurance Act, Chapter t03, General taws, 1917, and amendments thereto, that the above named employer hos become o subscnber under sa*d Act and amendments thereto end provided for the payment of compensation to employee* under the terms ind previsions thereof- Any employer or association wilfully tailing q' refusing to file *his notice shall be liable tor nnd shell pay to the State of Texas a penalty of not more than One Thousand Dollars {$1,000) for eocb offense.
EMPLOYER* SlGi
INSURANCE COMPANY SIGN HERE
SIGNtO .
TITLE OF PERSON SIGNING NOTICE
_TEXAS EMPLOYERS INSURANCE ASSOCIATION
NAMC OF INSURANCE COMPANY OR ASSOCIATION
#759. DALLAS, TEXAS 75221
AOORCSS
DATE SIGNATURE HERE CONSTITUTES NOTICE ON BEHAI F Of EMPLOYER
NOTH. RETURN THIS NOTICE TO; TEXAS EMPLOYERS INSURANCE ASSOCIATION
DO NOT MAIL TO INDUSTRIAL ACCIDENT BOARD.
TITLE OF PERSON SIGNING NOTICE
SIGNATURE HERE CONSTITUTES NOIlCE ON BEHAI F OF INSURANCE COMPANY
Oh sr h-27-77 $7.5
ORIGINAL COPY
t 'TuCfoY. ` s a.7S
*'- * ^ vV.. ` V
^(dCAi^;OF..WSKiiNtmf STATE OF-TEXAS
O DIVIDED RISK-EXPtAIN OPERATION COVERED BY THIS fOUCT
'^ 'r
ll
POUSY MUtfftCffi
. 1P-B-59W
... ..
D NEW POLICY
O RENEWAL
EFFECTIVE OATS Ul#f AM 6-1-76
{1 CANCaiCO i
EXPIRES AT 12:01 A.M. ON_^M!L
r mwmiuiee C"TM| 1 ' 1
VSk
APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:--2Z-------
B. Seasonal Employment by Month;
IAN. [ FEB. 1 MAR. j APR
1j
|
MAY j JUN.
OfHe or xc&a&ge as^Xoyees
_____
~ ""
i
JUL
jp--j--gff
11
NOV! r~0EC
.
AGT. on BROKER
ADDRESS
CITY
STATE
ZIP
Notice is hereby given by the named employer and th named insurance company, os required by the Texas Workmen s Compensation Insurance Act, Chapter 103, General laws, 1917, and amendments thereto, that the above named employe' has become o subscriber under said Act and amendments thereto and provded for the payment of compensation to employees under the terms and provision* thereof. Any employer or association wilfully failing or refusing to Me this notice shall be itoble for and shall pay to the State of Texas
e penalty of not more than One Thousand Dollars (51,000) for each offense
04 ed 4-7-76 $7*50
I A B Approved # >0 I XV UiA 30130 111 Sft
ORIGINAL COPY
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MOTKf THAFCMW
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af. ..*
SfvADDRESS: ^3 licgtiYa Ctateff BWL' 3& jii/f2t*v
LOCATION OF RISK: ENTIRE STAFF OF TEXAS
0 *t >\\ 1 T - ''.wvi-r ,.T^*-.
DIVIDED RISK--EXPLAIN OPERATION COVERED BY THIS POLICY" H
t RQtLtcV MUMBEft j 0-59127
effective date U:t am 6-1-75
' >, > 7c"
{ CANCELLED |
(NSURANCC CO.-JWI
O NEW POLICY
D RENEWAL
3 EXPIRES AT 12:01 A.M. ON
S-lr76
APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:.,_____J^7
_,
8. Seosonol Employment by Month: | Xan~ j per f ~m*. j aw. | m~a7 "~r~~10H r~~7tiE--j~ au& j sEF f~~c%T. J nOv. j pec,j
OCCUPATION
Office or Exchange Employees Iticl. drivers
ACT. OPT BROKER
ADDRESS
________ ____ ___________ _______ ___
CfTY
STATE
ZW
Notice is hereby given by fh named employer ond the named insurance company, as required by the Texn* Wokmen's Compensation insurance Act, Chopter 103, General laws. 195/, and amendments thereto, thot the above named employer has become a subscriber under sod Act and amendments *hereto ond provided for the payment of compensation to employees uniitfr the terms and provisions thereof Any employer or ossooation wilfully fading or refusing to file tb*s notice shaM be itoble for end sho{{ pay to the Stote of Texas a penalty of not more than One Thousand Dollars f$ 1,000) for ecch offense.
I EMPLOYE K>N
INSURANCE COMPANY SIGN HERE
JBUiQffLOYERS INSURANCE ASSOCIATION
TTiCIITflOP INpUNANCC COMPANY OR ASSOCIATION
SOI 2759, DALLAS. TEXAS 75221
{DATE__
tlTLl Of PERSON SIGNING NOTICE
475
SIGNED,
SIGNATURE HERE CONSTITUTES NOTIfE ON BEHAIE Of flPIO
IN XtS DEN T BO,
NOTE: RtTl'RX THIS NOTICE TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION DO SOT MAH TO ISDUSTRIAL ACCIDENT
BOARD
TltLt OP PERSON SIGNING NOTICE
SIGNATURE HERE CONSilUJTES NOTICE ON BEHAI F OF INSURANCE COMPANY
04 $7.50 nr 4/15/75 ORIGIKA1. COPY
'iD .f
^;*/y
%'***'f'iic5f:!b? 'te**oft-F ihe designation of Tex** in'Item * of he tiei;i^ ,. ,
*Pf*ty
meiudin^ death resulting therefrom, sustained by any executive office*'.', " '
*k pfoptiewt' of the.injured, except such, if any, as arc designated below ot in item 4 of'tile 1 ,^.\w*v
ptffo*'-,'.-*N v- declarations.
3, ` 'Remuntratisn," when used as a premium basis for such insurance, shall not include the (enumeration of any executive officer, partner or sole proprietor of the insured not so designated.
Designation of Persons
This sodorseswot shall be subject to ad of tba toms, provisiom and eoodUkm* of the Policy, sod octhlnf tenia contained shall vary, attar or extend aay tom, pt
vision ot ccfloicofi oi me roitcy except as hetei* specittcaiiy stated.
This endoiseiieril, when signed by a duly Autharircd R*p:entative of fte Company shall tom a pan of
SolTcv^.um8E
TM" --
- _TM_ --
_____
_
------------
a?59m____________ _________ __ ______ _______ _____________________
issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION of Pallas, Texas
9m Btoict-aifl gfcaiet Wejtai* mad friagHUh Cmmm* 933. fltth Sta*t, &envsr, Cc 80ES32
and ska.l m e**f,crve on fdatmt
June 1, 1975
EtEtlt,i data as the heui ol day provided by the Policy tor cosmetic*oenl oi f tfc Poiicy 4e.nod, and this endoiseaeat shall tom;nieith die Policy.
O'OlVIKD'tfSSC-i-SWtAfH OPERATION COVERED BY THIS POUCY
? ***-?
KM.CV NUMWm I-5P27
--__
I
vntcrvnt. oatc \m\ am 6-1-74
| CAVtCStLSO 1
MaiiiiiMciUiw'A.TA^ mm
O NEW POLICY
n RENEWAL
H EXPIRES AT 12:01 A.M. ON,,........ 6-1-T5...
APPROXIMATE NUMBER OF EMPLOYEES:
A. StabW Annual Employment_______ _________________ ______
B. Seasonal Employment* by Month:
Ian!
fci. )" mail T^amT ( MAY~T~jufT j iui. f~auo T sfp, ~~T our
no7
5BT I
OCCUPATION
tssaplayftgg
clerical
AGT. OH BROKER
ttot.'R is hereby given by the named employer and the named insurance company, as required by the Texas Workmen * Compensation insure, nee Act. Chapter 103. General lows, 1917, and amendments thereto, that the above named employer has became a subscriber under said Act and amendments thereto and provided for the payment of compensation to employees under the terms ond provisions thereof. Any employer or association wilfully foiling or refusing to M this not re shall be liable for and shod pay to the 5tate of Texas a penalty of not more than One Thousand Do'lars ($1,000) for each offense
ami mi--nawi numiM wnuinr t -- m -- .ww-mo^amii.NBm..-- -- am i mn-aw>vqft
y.yaMFtOXER SIGN
SIGNFO-
lOAre
TITLE OF PERSON SIGNING NOTICE
i INSURANCE COMPANY SIGN HERE
Sffim_
TEXAfrE|IPL0YERS INSURANCE ASSOQA
NAMB^OPJ^SURANCE COMPANY OR AjrfjpfStion
?! t vacSateW-ms./Au^s. TEXAS^Q
*iv%
JSIGNEI
(
I SIGNATURE HERE CONSTITUTES NOTICE ON RE
NOTE: RETURN THIS NOTICE TO:
iTEXAS EMPLOYERS INSURANCE ASSOCIATION DO NOT MAIL TO INDUSTRIAL ACCIDENT BOARD
3m
TITLE OF PERSON SIGNING NOTICE
SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OE INSURANCE nCMPANY
I A I A^p<o*4l 8 >0 1 < Z tf(A mUHI.ARI
hd 5-8-74 04 $7.50 ORIGINAL COPY
O NEW POLICY
S RENEWAL
QJ EXPIRES AT 12:01 A.M. ON
6-1-7**
APPROXIMATE NUMBER OF EMPLOYEES: ^ A. Stable Annual Employmflt:,,_J?^..
B. Seasonal Employment by Month:
1m. 1 fR 1 MAI.
11
. API..
MAY
jUN, 1 JUL I AUG.
II
Office or ixx.GhB.nge employeea including clerical
OCCUPATION
SJF C~ off.
|
NOV. I DEC.
|
A6T OR BROKER
AOORESS
C?TY
STATE
zm
Notice i$ hereby given by the named employer ond the named insurance comoony, as iequired by the Te*o$ Workmen's Compensohan insurance Act, Chapter 103, General Laws. 1917, and amendments thereto, that the above named employer has become a subscriber under said Act and amendments thereto ond provided for the payment of compensation to employees under the terms and provisions thereof Any employer or association wilfuiiy failing or refusing to fil* this notice shall be liable for and shall ooy to the State of Texas a penalty of not more thon One Thousand Dollars (>1,000) for each offense
INSURANCE COMPANY SIGN HERE
|WTE
gr.jSTF11
SIGNATURE HERE CONSTITUTES NuTiCE ON EEHAtF OF MPl:
i NOTE: RLTL'RN THIS NOTICE TO.
TEXAS EMPLOYERS INSURANCE ASSOCIATION
DO NOT MAIL TO INDUSTRIAL /f(V
BOARD.
}
TEXAS EMPLOYERS INSURANCE ASSOCIATION
'Insurance company or association
X 2759, DALLAS, TEXAASS .
. ADORES r^rjp--
nut or rersoN sk.h)nc NOTtct
SIGNATURE HERE CONSTITUTES NOTICE ON 8FHA OF INSURANCE COMPANY
'*P
R*v it* 4^
tf i* *0*1 O (II *#!
04-0240 7.50 as 4-24-73 ORIGINAL COPY
{
POKY MUMSSft
|
[ D-59127
|
O NEW POLICY
B RENEWAL
fcPFECTIVe OAT* T2:1 AM
CANCELLED
MtfSUJIANCf CO. -1
6/1/72
mu
L - ..........................1
B EXPIRES AT 12:01 A M. ON.................. 6/1/71
APPROXIMATE NUMBER OF EMPLOYEES: A, Stable Annual Employment_________
967
B. Seasonal Employment by Month:
[ JAN. ~|~~FlBr~T~~MA. I A?r~T MAY* r ~JUN~ T JUL.
I
NOV.
PEC.
OCCUPATION
Telephone or Telegraph Companies_____________
ACT. OA BOOKCH
ADDRESS
________________________________________________
CITY
STATE
2IR
Notice is hereby given by the named employer and the named insurance company, as required by the Te*o< Workmen s Compensation Insurance Act Chapter 103, Genera! lows, 1917, and amendments thereto, that the above named employer has become a subscriber under soid Act and amendments thereto and provided lor the payment of compensation to employees unde' the terms ona provisions thereof Any employer or association wilfully tailing or reCnirg to file this .<ohce shall be liable for and shall poy to the State of l>*as u penalty of not mor* than One Thousond Dollars (i! 000j for each offense
dfER SIGN,HERE^
v~/Q
INSURANCE COMPANY SI&N HERE
StaNE D JT
TITLE 0^ PERSON SIGNING NOTICE
TEXAS EMPLOYERS INSURANCE ASSOCIATION
INSURANCE COMPANY OP ASSOCIATION
BOX 2759, DALLAS, TEXAS 75221
DATE_____ SIGNATURE HERE CONSTITUTES NOTICE ON RlhfCT^t; tMEtCTFR j
NOTE K7TTURN THIS SOME TOTEXAS EMPLOYERS INSURANCE ASSOCIATION
DO SOT MAIL TO INDUSTRIAL ,i< i il)l Vf HOARD.
cr/4/14/72
7.50 -i-frrr'
- - nj
l. or PSPSCN SIGNING NOTICE
SIGNATURE HERE CONSTITUTES NOT ON 3EHAIE Of INSURANCE COMPANY
r.
ORIGINAL COPY
aJUkijm'Jte.-jK?* &S%?gr-3*:-`SSrSyj.
->>{.: Vi.:->&f* rkm=^
pigif:;
**'V* V'*-' ` \"tyv' i* "" "e> ' - '*., ", ~>A* ^ V '** ?, * v .'; " *
f
, ,. .
'T <*r-r' ' ' ' '
`"'V> _,*>
EXECUTIVE GKE1CSES ENDORSEMENT - TEXAS
`'
; ,* vGmg' Vri***
' tit*. ,,
"%
le is sirred disc:
i. The insured being s corporation, such insurance as is afforded by die policy by reason of the designator
of Texas in Item 3 of the declarations does not apply to injury, including death resulting therefrom,
sustained by any executive officer of the insured, except such officers, if any, as ate designated below or
in Item 4 of the declarations.
"Remuneration,'' when used as a premium basis for such insurance, shall not include the remuneration of
any executive officer of the insured not so designated.
Designation of Officers
^a>
Hone
This endorseweitt mill be subject to ill of the terns, provisions end conditions of the Policy, tod nothing herein contained lh*U yryr jltar or ertend any tern, pro
vision or condition of the Policy except as herein specifically stated.
~~ 43-^
This endorsement. when signed by a duly AeUwrired Representative of tha Company shall fora a part of POLICY NUMBER
0-59127
issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION ot Dallas, Taxas
TO 423 Executive Center Blvd.,
The Mountain States Telephone and Telegraph Company
El Paso, TX 79902
AND SHALL 0 EFFECTIVE ON
June 1, 1972 SIGNED AT
at the mate hour of said data as tha houi ol day provided by the Policy tor cotntntnceinent of the Policy Period, and this endorseneat shall tiiainate with the Policy.
j Bv
Delias, Texas 4/14/72
j^
AUTHORIZED REPRES*TAT(YE
TEl* 17,nft 14-14-47
WPP"
,^aausse&s.. .....
SSM _
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oiK-'Y :..'''fi^
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--^..,.*r*?>' *- - -
f|gC|r^l.PF'.^t jgEKIgf^TE QttfXAS
Beso. twm 'mot '
"'tf';-''",''v,v`'
0 Divided .fitSK-explain operation covered by this policy
Rc :T; m fl - -r-4
,f
POLICY ttUMSC* 0-59M7
CPPtCTIVK OATS H;#1 AM
Jam I, 1971-
CANCCLLSO
meutUMcceo.
TSIA
O NEW POLICY *
Of RENEWAL 20 EXPIRES AT 12.01 A.M. ON Jana if 1078
APPROXIMATE NUMBER OF EMPLOYEES:
967
A. Stable Annual Employment:___________ ________,,_____________ _______________________ _
B. Seasonal Employment by Month:
JAN. |1__. F_EB_,
MAI.
1
OCCUPATION AGT. OP BftOKCR
TELEPHONE OR mEGRAPR COMPANIES
Notice is hereby g.ven by the named employer end the named mwranc* company, os required by the Texas Workman's Compensation Insurance Act. "hoptor 103, General Law*. l'? 17. and amendments thereto. that the obo.e nomed employer has become a subsenber under sotd Act and amendments thereto and provided for the payment of compensation to employees under the terms and provisions thereof, Any employer or association wiHully roiling or refusing to file this notice shall be liable for and shall pay to thj State of Texas a penalty of not more than One Thousand Dollars f$ 1.000) for each offense.
SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMP10VFR |
NOTE; RETURN THIS NOTICE TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION DO NOT MAIL TO INDUSTRIAL ACCIDENT BOARD.i
iffAUB WAOppOov1e1a14*' 10 J 4*
cl/4-30-71 ORIGINAL COPY
ssw,f'CTr< ,;V i'
^.*30^
& JWW, *^r-`
^ 1
'vVv ' - ' <
'*:
gfeKtfeone aaft. S&lagrttfc Cosgaay
- :-. i.l.irrrm mri ' r UJ- 1 " "
'
*. ,vrA$?
'Wi&'gtoMt; -Peatg; CO 80802
S ENTIRE STATE Of TEXAS ' O DIVIDED RISK--EXPLAIN OPERATtON COVERED 8V THIS POLICY
-Si
--- -*f' gilfowmfejpi
. ** . ? V^>j
m
j J"
Ksust uomtta
'' B-3912T 1 I________________________ .
f O NEW POLICY
IS RENEWAL
IfHCTIVK OATS IMf AM
AMCOUM
6-1-TO
.
3 EXPIRES AT I2:0*i A.M. ON
MMMAMCxee,
TSIA
( j
6-1-71
I APPROXIMATE NUMBER OF EMPLOYEES: ; A. Stable Annual Employment:,______ _____ 2^L
i, Seatonal Employment by Month:
m. | mm. j m.
_________1__________L
MAY iUN. I AH, 1 Al): r-mr-1 "6Cf. y 7357 "5iTTM-'
1 L____J____
_____
_________ t------------
ecurATio*
_ __Office or exchange employees including cl>risal.___________________________________
A6T O* 0AOKE*
AOOHrSS
CITY
STA'T
*
it hereby 9<vn by th nom*<j #mpkpyr ond th# nom#d *nyronc# Compony o* n*^.r#d by fH# T*o$ *fcpffem*n Comp#nto<*on
rnturoYV Ac Chop**f 103, Gn#fof low*. 1917, ord omodr ,.ls
Ho th abov nom*d n*ploy*r hot bccom* a *j6*cnb*f
nnd*r Ktid A."* ond Qmndmnts thrlo ond provided for tfi payment of compr.*o*ion to npray! ondr fv t*rms ond provision*
throf Any employer or OMociation nnituliy fotlino or rfuytng *o fri# tS-$ notir sNoil bo I'obi* for ond shoil pov to thJftt o* T*xo$
a o*nolty of not mor than On Thovio id Do'lon ($1 0OGJ ter oet> nf,n%
iGfi*Tipf HfCONSTITUTES NOTICE ON HfHATT Of EUPiOTtK I
NOTE RETLRN I HI* NOTICE TO. TEXAS EMPtOYEBS INSURANCE ASSOCIATION DO NOT MAIL TO ISIH'STR! 4L ACCIDENT BOARD.
* 1 * -e-, .nr t*. 0 1.* v,,sc M.**.
;,-o,,-yo
ORIGINAL COPY
~n HaTnueT
Q room. of rcucy
EJTECTIYE AT 12OT AH. ON
HRIRES AT 12:01 AJ. 0*!
BO-. A-50127 WO: ____ _______
VXXM* v *
QJ ENTIRE STATE Of TEXAS
I I If MM iak 0m apursttaj cmwti hr thto uo&:j'
OCCUPATION
6-1-63
___ ____
6-1*70
APPROXIMATENUMBER OF EMPUOYEES
A. STALLS AMfWAl MAM-OrMNTTM__
3&L
B SgAAONAt. rimOYMKHT BY MQW^H ___
! JANUABY
I MAY
' crm*
1 PUBUARY ( MAftCH |
AMYIL
f
| JUNt | WtT | AUBtMT
OCTOI9t
NOVCMCA
t OCCtMKt
Aecxr o* mmonim
ho smxrr
Ccopaaicft...
CIT>
(Mica ta berat? ^wa bf toe mod araptojw mi toe *<ma4 tminac* omvwt- raomra-i by tit* Tnco
CeawRteffe* lewr*r Act Cluvtv Id, Ganant
Laws, 1917. mi Mwimti tharato, that tea above mmsi enffc^wr baa kvtm a aufceeribar Mar uM Ad antf amMnKMtx toarate and prvMii far Qa papaest of aa-
HmmUw ta eatotoyaaa mate tee turn mi mvfamm BMmf. fmf tmp'ezu Of eeaodatfan wwuJIy faffing or rafuatof to fa# tMs aotica Ml be babte far mi t"- Wi
to too State at Tam a ?e#*#T of not atsra Bit* Om TbwuM Doflan ($1,000) for eodi efferent
EMflOTE* S&: l**A SIGNED:____ .WLfL
f
7TTLA or
NOTH'*
I DATE- _ -....... ........... ... - . .......................................... - -....................
j SIGNATURE HERE CONSTITUTES NOTICE ON BEHAlf Of EXRIOTER I i NOTE, `urns l HIS NOTICE TO TEXAS TMPI OVERS' j r SI RASlE t IMI NOT MAII. TO INDVSTRIAl. SCriDFNT HOARD
tA-B to tl trOBUCftlV $&->
_______ __UNDERWRITER_______________________________ ___
TlX* 07 PtMOtt *'BNINB NOTICI
SIGNATURE HERE CONSTITUTES NGT'Cf ON BEHAlf OF l*SU*AC? COWRANY
*, ft it j-.eed dwss
1. Hie ineared being corporation, each insurance a* is afforded by the policy by reason of the designation of Texas in Item 3 of the declarations does not spply to injury, including death resulting therefrom, sustained by 3(iy executive officer of the insured, eacept such officers, if any, as are designated below or ;n Item 4 of the declaration*.
2. "lUmuuerauon," when used as a premium basis for such insurance, shall not inciude the remuneration of any executive officer of the insured not so designated.
Designation of Officers
Tins tidsnaasat tlxii te srt^tet Is all s< Dw Mint, premiers tad conditions ot Du Policy, nod net*ls|
KSW* & confition of He Policy ttcapf M Pettis spocifkally slaM.
Tins oOMuaenl, *k*n iif.m ky o duty Asnoorte Anv'awntntiv* of DM Coepany shall lots a part ot
no-
nm mmmm mmm 'MmIIMIllI CHI
*WO C**CCTIVt CM f*M>
Jn l i'W i*4to nr
"
Dollos, Texos WT^f
?K' ***
issand Oy Dm TEXAS EMPLOYtM' MSUPARCE ASSOCIATION of Dallas. Total
mn& mmm >?,1 14 th Street D&nver, Colorado it tN uw fcoof of date ft* tow cf d*y povidod by th* Policy for csoflf**
of fh* Policy Ponod. thi* eodorstwtat f*al' tefiiMt* with tt* Policy. far
12 NOT reucr
TXlSSOW r* POMCY
Wft M-A-59127,..f........................... ..................
UJWnOH 3f BSfc
12 ENTIRE STATF OF TEXAS
LJ If dhrfded risk, firs operate* mmntf In this o*cr
OCCUPATION
j EFFECTIVE AT 12.Ul A.*. ON
EXPIRES *T 12 01 AM. ON
` June 1 t .LVOV ______i__ June % 1970
APPROXIMATE NUMBER OF EMPLOYEES
A STASH ANNUAL CMPLOYMCNT_____1 QQ^
SCASONAL PMPn.OrMNT SY MONTH
| JANUAPY
4------------ ^ ------ r
I rtuA r
' iVNI
1 MARCH APNlL
t
StPTrMSC* I
fjr:
H4VIMWK
rterMAtP
AOINT ON MOPS*
NO ITHUT
I. ''fctroua,.2HL Ixrlh Cretan*--
CITY
23..sc3cJrftra.-23SCg.
Kobe* is hereby yivtfl by in* named awployar sod the named insurance company, as required by the lasas WorioTWVi Compensation Insurance Act Chapter 103, Goners! Urn. 1917, and amendments thereto, Out th above named employee has bacoma a subscriber under said Act and a<r*rdnwnts thereto and p-ondad for tha payment ei ompumtiQfl to employees under tha farms and prowmoos tbernof. Any employer or assodtfioo wilfully teilin* or refusal to fde tms notlra shah be liable lor and sftmflf pa; to tha Srite of Teas a penalty of rat more than One Thousand Collars ($1,000) for ncch eftansa
fAAI>IOE SIGH HFRt *//' /
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[ '*- A. I / TTV* OP PCMON SlSNINS *T'C
DATE
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SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF Of EMP10YFR
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INSURANCE COMPANY SK5N HERE
TEXAS EMPVOYERS* INSURANCE ASSOCIATION
'dAWC <>r tNU*ANCC COMPANY Off ASSOCIATION
A* 2759
OATLAS, TmL/5321
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______ UNPERWRITFR __
-TTLC OP PCASON AfONINS HOTICt
( SIGNATURE HERE CONSTITUTES NOTICE ON BET-Alf Of INSURANCE COUPANY
!it ajrefctftist;
1. The insured being a co(potation, much insurance a* ia afforded by tie policy by reason of the designation of Tex** is Ires 3 of the declarations does noc apply to injury, including death resulting therefrors, sustained by any executive officer of the insured, except such officers, if any, as are delivered below or in (tent 4 of (he declarations.
"Remuneration." when used as a premium basis for such insurance, shall not include the remuneration of any executive officer of the insured nor so designated.
Designation of Officers
SOtit
[SSElm
Til* emtorMaast stall ha
lo ill of (ta torn, oromioo* oaf comfitleas of Bio Polity, oaf
vttioa or coesitioo ot tta Policy p< >,< itac.ficiitr shad.
Tfn tadorsoaoat, aim sitwd *y duty AsaeruoO Soortuieoim of dw Coaooar than fora o port of
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stall vary, tiur or crhwf say jora. on.
A-59127
mow fry tfu TEXAS EtffLOrEM' WSUPASCE ASSCCUntOd of Oi'Uy Ttroi
Tbe Mountain Stata* Talaphone and T,,legrmfto Company
* ho shah. ae ^rrfrc'fvs c* t4mnj June 1, 1969
at 0* un Sour of Mid dole is IW toer of day povxM by th* Policy to coaaotttoDoflt of tftt Policy Ptfrotf, iM tin tftdorsoftfat s*u;i toraiflaio wift tM Pol.cy.
Dalles, Tcaos ` ft A ' ,a a ' a a
7-17-69-
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6-1-69 ~ 'JuS^w 6-1-70
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Q BTOII ^ATI Of TEXAS w#4 Sr fV* pAfe?
~
OCCUPATION
Telephone
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Owttrot L*v, If17.
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Act
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Texas, Bene?itJWifii*.tr*'t9r.._............. TITU: or PfltPON HONING NOTICf
DATE
It A' - 1 3 - * S4orwr* fc*'* c*titwtn aoNc# /> khrlf of tweeter
fOtM 1*1 20-M 'Fonwl, !30!
INSURANCE COMPANY SiGN HERE
Ta Coajjenaaftoni j,,n*ur
KAMI <>T INUAANC* COMPANY OA AAPCOATION
306 South lkard Street .Dallas, Texas 7J>202..... ............. _
SIGNfO
Secretary _______ ___ ___
Tiru* or ri*0N laNixa sorter 5<gafv'r fcr roaihhitM *tc * btaf of IfHOKVMC* Caepeay
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TX-2.1 SXcCuTiVt OFFICERS EMDORSBIEWT. TEXAS .
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1M
MMitluoMte.
R MMntain State* TtfLapiWM & ftol*gpipb
it effective from ....J._j*p^^
It *>
1961
____jwj foies a put of Policy No.
Jt-63
ISM AM. Standard Tuee
iscuad figr Taxes topuatim ItaamiB# Gcnpaoy
Stilts, Texas
It ii >ff Out:
I. Tin insured being corporjtior., wen insurance as is afforded by Do policy by reason of the designation ol t.~ ,,-. jicn j of Bw
declaration* doe* not apply to injury, including death resulting tbotofrom, si'~id by any executive officer of the insured, except luce
uffteefS, if any, as arc designated below nr >*
4 w cm declarations.
Z "Remuneration", when used as a premium basis lor such insurance, skali not include By* lemuneration of any executive officer of The instated not so designated.
Designation ol Office's
Non*
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and fnoorv^ents *ttACh*d tteryto
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Uilias, foxas
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) J. H. Zorwalt
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POtM t Al 20- 3$ f***ri? HO