Document dnXNXdwyoVNjr1JrdNZ92KRnQ

Co'tttcitsion No.. - ** annex mmmm.-.. _ - '. It ii &r*4 tM b*i 9*m f t&* twn4 in Ttn X of *h RoolAmtioB# f . :'/*'*^5?^';'^ ta Ptiijr l* ac*tt44 to rtmdt /Vi* f co X/- V{)^ . .. ' ' " i w. fl Contryetom, Ine.^jjonte*! & Km, Inc.L * Vholly ovntdi *Kbl<Jl*y -fc,i;;T:.4:3-; (if. S. Cotrffvfertor*. X*e^t B|*tftcfiM iMkrttmutfitlea, fuel, * &#Iljfc> '* ` r^?- vwwrt tcSiiUteiy of W. n* Contrutora, Ine. *, .>*''.- t-- PLAINTIFF'S EXHIBIT DOW-2900 V. , i ' -*> t ' - ; .. ,. - - - ,,*'**V'' *&5~W : :-v .v.'k? 3*"', v * ,Vi'. 'v * * ... *'v,y,,*' ' -! " v^'c*.' -*t->--'v . - -!, > Thi* endorsement shea be Subject to stt of the terms, provrstorra end conditions of the Policy, and nothing herein contained shall v*fy, after ofextend enytiW(7 provision or condition of the PoBcy except*herein specifically stated. * This endorsement forms e pert of the Policy to which it is attached issued by the Company designated on the Declarations Page and is effective from the incept: tion date of the Policy uniass otherwise stated below: .. ., {The information below it not required whan this endorsement is Issued`with the Policy! fouev number 9C-t-3910 certificate number ta*u*o to 0* S* Contractors, Inc* EFFECTIVE January 1, 1951 StOHED AT Dalias, Texas at the same hour of said date as the hour of day provided by the PoBcy far commencement of thepoiicyperioci, and thta endorsement shall terminate with the Policy. ' -. *k t*A. <Tb.buATt------------------------------------------------------------------------------- ----- Texas EtTiPLOYeRB' insupance Associanon THA357GD 112-781 EXECUTIVE VICE PRESIDENT AUTHOBHEO'hCniUaywtATIVE V fv" t ^ s' , - ,Sfc "*/*{W '"r, Uc} i*-'t*fy^*-t' - V*$ -pt. ht,m> . ,. . the .JNft*..<** ___ i*S%"| iwwm .,,,. ,.,.,. '. - < l*h > +.*>.,.y , ... , ',, t--*x**#$&***&#evtfSRKiUmf^***** ' fi&z?Y'',,S 1 <- .w,- ' &&**' **/ " .......... .. ../.iSLSfSisf 0* S ttteirv&wtK*, tatoej Weski % Rea, !* * RteU? a*4 iwWS#1Jliy ;M ; .*1 lr* 3. Cdtraetor, lne t l*nU4 Sleetrleal aivS ,, oi9s i}be{dii7 !op. y*. Sr* Coatmet^ra, ine. .t-W- &9s*< .ylC9?3! . v^^sgsia -v > *t }:&&$$%tf^i u 'w*. r * - y~sys>hf<.\I V pv' .\J'} 1 vf/Vr^v';, v';^;| I 4 ' '* '. ?. > .-.<*? jyi's&'SS^ *& V'*^!oi -' "'YSff ''l.^Kl ''s^L, , r-Tflj41 ;, : ;Sv Rr>r ;?%a this wdwwmwt shad be subject to ad of the terms, pravisions and conditions of the Poficy, and provision or condition of the Poficy except as herein spedficaVy stated Thd endorsement forms a part of the PoHcy to wffich it is attached issued by the Company designated boh date of the Pofiey unless otherwise stated below; . vjy.v '-v extend any tarm, from tho.&tcep- - (The information below is not required when this endorsement Is Issued with the Policy) ccrmncATc numscs issuer to ,^ "ont rsietora. lae t,rtC*?;frttr % 15T' zr. i?'.n SIGNED AT Dallas, Texas at tha *ma hour of laid data at tha hour of day provided by tha Policy for comnwr.^amant of the policy period, and this endorsement shat) terminate with the Policy. Texas EmPioYena1 insurance Associa-rian TBA 36780(127* Exscumn vice reieiDCNT AUTHORIZED HEeWEeEHTATtVt NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER ' *v < TEXAS WORKERS' COMPENSATION ACT Nolle* It hereby glvnn by the named employer ond thr* Inturance company, a* required by the Texa* Worker*' Comp#natlon Ifttiiranc* Acl, Chapter 103. General lows. .917, ond amendments thereto, thnt th* now*-1 employer ho* become o subscriber under cold Act ond amendment* thereto and provided lor th* payment of f-ompemotlon to employees under the term* ami provisions thereof. Any employer or association wilfully lulling or refusing to file this notice shall be Koble fo* o*d shall pay to th* State of Teeos a penalty of no! mote thon One Thoutand Oollats ($1,000) lor each offense INSURANCE COMPANY SION HERE no not 0:1 o*ou namu i'iW0 TEXAS EMPLOYERS* INSURANCE ASSOCIATION AM? Of (WUtANCC COMfAN* OB MSOCtAtlON 'BOX 2759, DAltAS, TEXAg%?2f APORflt i yS;ICttiE&> \cri ypIGNATURE'HERE CONSTITUTES NOTICE ON BEHAIF OF insurance company POllCy NUMBER:_____ -------------------------------------------------------------- a NEW POLICY EFFECTIVE: FBOM 1 RENEWAL 1"1~79____TO__ 1-3.**8Q-------- AGENCY WRITING THIS COVERAGE- NAMt ~~ ~ ~ * Aopynr '' ~ *' ~ * twowt kum>k (MMFOIATE PRIOR COVERAGE WAS IN EFFECT FOR PERIOD FROM;TO;____ ___________________ THROUGH- (INS CO ) {NOT SfQUIVfO rt BfNfWW IN SAMI COMPANY* ............. .. ............ ............. POLICY NUMBER- __ ___________________________ SCOPE OF COM RAGE 3C1 ENTIRE STATE OF TEXAS (Alt OPERATIONS! OS PROPRIETOR AND OR EXECUTIVE OFFICERS INCLUDED NOTICE FOR DIVIDED RISK POLICIES COVERING I.'tCIFIC JOBS. JOINT VENTURES AND FOREIGN OPERATIONS MUSI BE FILED ON I A B FORM 154 H REINSTATEMENT REVOKES CANCHLATION EFFECTIVE OCCUPATION OF INSURED -------- ______________ nfT Ra-PTnTrtg TTnSfcn TgrEwstSms p. Repair 4tfX Operations & D ' APPROXIMATE NUMBER . OF EMPLOYEES_______________ . ______________________ ______ ESTIMATED ANNUAL PAYROLL _______ $630,617. 8EIOW list PRINCIPAL CORPORATE NAME FIRST. GIVING HEADQUARTERS ADDRESS. THEN UST EVERY SUBSIDIARY CORPORATION DOING BUSINESS IN TEXAS AND PROVIDE ITS PRINCIPAL TEXAS AOORESS ALSO UST EVERY OPERATING OR DIVISIONAL NAME USED IN TEXAS AND PROVIDE THEIR LOCATIONS CONTINUE UST ON SEPARATE SHEET AND AT. TACK IT. S. Contractors, me.; Monlcal & Rea, a _ irtiolly owned subsidiary of U. S. Contractors, >I j lnfyAI; _6?2 .Cownarce Aye, ! signature here constitutes notice on behalf of _P. 0, .Drawer 147, Clute,.Texas 77531 I employer tmtof,!<>*(ski,notice i j I A 8 Forn ;t*v 0 rn 1UA 3013 F <\ 701 02 ,ja i2/1^ ORIGINAL COPY ADOl i IMMEDIATE PRIOR COVERAGE WAS IN EFFECT rQR PERIOD FROM- TO: PHONE NUMBER THROUGH: (IMS. CO.l <ww mull wwo w ui tmumt) BELOW IIST PRINCIPAL CORPORATE NAME FIRST v>iV(NG - * aO- QUARTERS ADORESS: THEN LIST EVERY SUBSt**?1' CORPORATION DOING BUSINESS IN TEXAS ANO PROVIDE ITS f M. TEXAS ADORESS. ALSO LIST EVERY OPERATING OR UIVIS; .)N*l NA**t USED IN TEXAS AND PROVIDE THEIR IOCAT. CONTINUE LIST ON SEPARATE SHEET AND ATTACH. U. S. Contractors, Inc. FnmX"338 EaKe 'JacKsoh, i`A VY>66 POIICV NUM8ER: EMPLOYER SIGN HI SAUS.N' EfOew^rT?/v^-- TlTlE Of PttSON SIGNING NOTICE DATE: _ _____ SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER I A fonn 30-77 (*,, ft 77) HtA 3013-E (ft- 77) ORIGINAL COPY NOTICE THAT EMPLOYER HAS BEC :R TEXAS WORKMEN'S COMPENSATION ACT 733)0.... * ' 1 "^t' t*"l C'M^OYERl oil firm rn"M. ond compUlp jr*nling addru. covind by ihit policy under which operation* ot co^ducl*d Jo T**ov Attoe'nfdvJ iM^ritoty Oc.Nsr.TvpnU V |y U. S, Contractors, Inc* ADDRESS; _ P. 0. Box 336, Lake Jackson, TX 77566 -Li- LOCATION OF RISK: ENTIRE STATE Of- TEXAS E DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY SEE ENDORSEMENT ATTACHED POLICY NUMBER E-63910 EFFECTIVE DATE U:01 AM 1-1-77 CANCELLED INSURANCE CO. TEXA NEW POLICY S RENEWAL SS EXPIRES at 17 01 A.M. ON_ 1-1-78 APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:51_________ B. Seasonal Employment by Month: MAI. API. Oil Refining Units-Ereotion or Repair OCCUPATION AGT OH BROKFR AUG. mBiEHr411 2311 mzd'77 rWTOCWOSOINeDfUfS^TRRIAoL*- Notice >s hereby given by the named employer ond the named insurance company. o*j Mho ttjixn Workman'* Compensotion Insurance Act Chapter 103 General lews 1*17 ond amendments thereto, thofthe/ ` has become o subscnKtr under said Act and amendments thereto and provided tor the payment of c-imfpnsotion^ ns and provisions thereof. Any employer or a%Aooa'0 wilfully btaaiilliing ocr refusing to hi* this rtohci sholl be lio0la?^r^JfK fcjlf^oy tofhe State tf Texas o penalty of not more thon One Thousand Decors (SI 000) for each olfense. EMPLOYER SIGN HERE Lpi .... TITLE OF PERSON SIGNING NOTICE TEXAS EMPLOYERS INSURAtKEASSOCIATJON NAINSURANCE COMPANY Off ASSOCIATION / / BOX 2759, DALLAS, TEXAT'jH?! DATE, SIGNATURE here CONSTITUTES NOTICE ON 8EHAIF OF EMPLOYER NOTE: RETVRN THIS NOTICE TO.TEXAS EMPLOYERS INSURANCE ASSOCIATION DO SOT MAIL TO INDUSTRIAL ACCIDENT jib 12-9-76 02 uu 30IJO autiIAS Apoiftftjti* 101At $7.50 < ORIGINAL COPY TITLE OF PERSON SIGNING NOTICE SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY DIVIDED RISK ENDORSEMENT - TEXAS Font TX-2 (10.1.54) It is ngreed tint: ]. Such insurance as is afforded by the policy by reason of the designation of Texas in Item 3 of the declarations does not apply to injury, including death resulting therefrom, sustained in the operations specified below, and "remuneration", when used as a premium basis for such insurance, shall not include the remuneration of em* ptoyees engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the busine** in which the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer: All operations required under the insured's contract with Dov Chemical USA Texas Division, an operating unit of the Dov Chemical Company (DOW); which specifically states that Dov procures the insurance coverage specified in the contract. Other operations, including operations at th Named Insured's regularly established main or branch office, factory, shop, warehouse or similar place are not excluded. This endorsement does not apply to any executive officer, partner, or sole proprietor covered under Endorsement TX-3.2 attached to this i "eCEfVEB JAW2 077 Texas industrial OCCIDENT BOA on This endorsasent shill be subject to ill of the bias, provisions vision or condition of the Policy eicepl as herein spedflcitly staled. This endorsement, when sljned by e duly Authorized Representative ol the Coapeny shall fora a part of Policy kuubeb C< i11 ITo D-63910 E-63910 TO U. S. Contractors, Inc. Isiued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION ef Oallas. Texes ANO SHALL BE EFFECTIVE ON (dM) January 1, 1977 SIGNED AT DALLAS, TEXAS " "' it the seae hour ol sold date as tha hour of day provided by the Policy tor coaaence* cent ot the Policy Period, and this endoisaaent shall faialrule with the Policy. 8V --f v. > - ^ --- AUTHORIZED KEf hESEhUttVE TEIA 3530 ( 10-1-50 / ts 5oo < Qmmmm K #. tHMr *r ** W TT9SX This endorsement shall be subject all of the terms, provisions a.id conditions of the Policy, and nothing herein contained shall vary, alter or extend any term, provision or condition of the Policy except as herein specifically stated. This endorsement, when signed hy a duly Authorised Representative of the Company shall form a part of polio"number c'rrYirfcatc~mumBin "" issued bv~the lS>a43SSa TO * * VO I ton ** " ' ' ' * Texas EmPLOYBRB' mauBance Assncianon oi dhm, Tcom ` '* " AND SHALL 8C CFFEC.Tl\t CN aMRMTJU-)9T7. SIGNED AT Pallas. Texfl* 1260 * %6>77 at the same hoar of said date as the hoar of day provided by the Policy for ment of the Policy Period, and this endorsement shall terminate with the Poli AUTHORIZED WEeacagNTATIVg POLICV NUMBER WC-P-63910________ NEW POLICY @ RENEWAL errccTivc date li.oi am CANCELLED INSURANCE CO. 1-1-76 TELA C3 EXPIRES AT 12:0! A.M. ON______________1-1-77 APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annua! Employment:____ B. Seasonal Employment by Month: JAN FEB. MAR. APR. MAY JUN. JUL. 1 AUG. SEP. ot. NOV. KC. Oil or Gas Refining OCCUPATION ~ AGT OR BROKEA ADDRESS CITY STATE Elr Notice is hereby giv*.n by the nomed employer ond the nomed insurance company, as required by tho Texas Workmen's Compensation Insurance Act. Chapter 103, General laws. 1917. and amendments thereto, that the above named employer has become o subscriber under said Act and amendments thereto ond provided for the payment of compensation to employee ' under the terms and provisions thereof. Anv employer or association wilfully tailing or refusing to file this notice shall be liable for and shad pay to the Stall of Texos a penotty Of not more than One Thousand Dollars ($1,000) for each offense. EMPLOYER SIGN HERE 1 *\ v\ ^---- JHHHHHI J'\ UflHFD 1` 4 V. J TITLE or PERSON SIGNING NOTICE INSURANCE COMPANY SIGN HERE flMMHHH TEXAS EMPLOYERS INSURANCE ASSOCIATION NAME Or INSURANCE COMPANY OR ASSOCIATION ySq? 2759, DALLAS. TEXAS 7522K? nATF- SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OE EMPLOYER U NOTH: RETURN THIS NOTICE TO: TEXAS EMPLOYERS INSURANCE ASSOCIATION DO NOT MAIL TO INDUSTRIAL ACCIDENT HOARD. % 02 1090 ag 12-9-75 $7.50 IAS Apgiot*^ It. 10 I 49 TCIA 10130(114*) < ORIGINAL COPY 1 5 '76 TITLE OF PERSON SIGNING signWPSKIRAlWfiiSETRffficE * ON ECTALF OE INSURANCE C0MPANT iam* 9f9* DIVIDED RISK ENDORSEMENT - TEXAS m It ir \grecd that: I. Such insurance as it afforded by the policy by reason of the designation of Texas in Item 3 of the declarations does not apply to injury, including death resulting therefrom, sustained in the operations specified below, and "remuneration*', when used as a premium basis for such insurance, shall not include the remuneration of eraployees engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in which the Texas operations described in the declarations are conducted: AU ywllm mrii4 Ntar ttN ltMOTtf*! iMtrtrt Bm Chm&ml MA tmm* BlviUm, mi ofunitlat mit ( Mm Bm clmrtMl Coapuqr (DOW)* MiW ipMiliMUl mhm ttit ttm pnnrw Mm laNram nnp U Mm Mitmt, irMwr lwtlwllt aymtUeoa al Mm 8m4 ,-#uUrl|r citMUlM a*im or birftscli offiM, Awtaiy, MMfo MNkMMM r *1*11*1 plats *r* not Kelnt44, fbUB iihrtiiirt 4m* o% ml| W **r miMlw fBrhmr, *1 pr*fl<rUr wwwl *twr ftiltr* firt 0.3.2 MMM to tU yMUf. JM11 5 '76 insurance dept. This endorsaaant shill be subject to all of the total, provisions and conditions of the Policy, and nothing herein contained shell viry, liter or extend any tone, pro vision or condition of the Policy except os herein specifically slated. This endorsenent, when signed by a duly Authorised Representative of the Coapany shall fora a part of *J. 8. coBtraor* Xm. signed at DALLAS, TEXAS TEIA 3530 (10-1-54) Issued by tha TEXAS EMPLOYERS' INSURANCE ASSOCIATIOH of Dallas, Ttxas at tha sane hour of said data as the hour of day provided by the Policy for coaaenc*nent of the Policy Period, and tills endc'tnent shall laminate with the Policy. SY AUTHORIZED REPRESENTATIVE c. ym FORM TX-U (9-1*73) #s EXECUTIVE OFFICERS, PARTNERS AND SOLE PROPRIETORS ENDORSEMENT - TEXAS It is agreed that: 1* Such insurance as is afforded by the p.lic\ by reason of the designation of Texas in Item ^ of the declar* ations does not applv to injurv, including death resulting therefrom, :;us?nin?d by any executive officer, p.irmcr or sole proprietor of the injured, except Mich, if any, an arc designated below or in Item d of the declarations. '`Remuneration." when used as a premium basis for such insurance, shall not include the remuneration of anv executive officer, partner or sole proprietor of the insured not so designated. R?SIS Designation of PersonSj|^|^ygT^'^" ** AN active executive officers JW1V16 \ iC DEP1"' shall fcims,This endorsem*nt be subject to all of Ibe provisions and condilions of the Policy, nnd-nnthlng herein contained shall vary, alter or eatend any term, pro vision or condition of the Policy escept as herein specifically stated. This endorsement, when sitned by a duty Authorized Representative ol the Company shall form a part at POLiCY NUMBER issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION ot Dallas, Texas TO a. So 1mi N is. me )3t, Uk jMkn, IX TT946 AND SHALL BE EFFECTIVE ON (d*t+) jMMHFf 1, Signed at Dallas, Texas at the same hour ol said date as the hour ol day provided by the Policy tor commence ment ot the Policy Period, and this endorsement shall terminate with the Policy. 0 ^ AUTHORIZED REPRESENTATIVE T EIA 17230* I NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER ^ Bill6Z563_________ TEXAS WORKMEN'S COMPENSATION ACT p ft ^ * - EMPLOYER: t .*? op*fo***ufln<lutl# oil fm sm*, o*4 maiV>g oddren. cov*r*d byThh pofccy ivf# which o* rondu*c*i*'d 1 nrvwtiotr *ndcKtrrr*,ftii 5 _ fA 1"1""35 o o J* t 1 ___,.S. Contractor*. Inc. ADDRESS: . P.0, Box 338 LOCATION OF RISK: ENTIRE STATE OF TEXAS O DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY .See_Enior#^cmCTiJt^tAftch.ed_ POLICY NUMBER 3-63910 EFFECTIVE OATE 12:01 AM 1-1-75 CANCELLED INSURANCE CO. TEIA , NEW POLICY 3 RENEWAL 3 EXPIRES AT 12:01 A.M. ON___ 1-3-76_ APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment:________ SI B. Seasonal Employment by Month: IAN. n& MAS, APR MAY JUN. JUL AUG. ^FP oil. NOV. DEC. Oil or Gob - Refining occupation"' AGY. OR BROKER AQORESS CITY STATE ZIP Notice i* hereby given by the nomed employer, and the named insurance company, os required by the Texas Workmen's Compensation Insurance A<*. Chapier 103. General laws. 1917. and amendments thereto, that the above named employer has become a subscriber uncler sod Act ond amendments thereto and provided for the payment of compensation to employees under the terms and provisions thereof. Any employer or association wilfully tailing or refusing to file this notice shall be liable for ond shall pay to the State of Toxas a penally of not more than One Thousand Dollars (SI.000) for each offense. vision EMPLOYER SIGN HERE / , o (j.>) INSURANCE COMPANY SIGN HERE y^C*. V?.o a RECEIV "DTrrue oT^person stWi W&iaC acciJent TEXAS EMPLOYERS INSURANCE ASSOCIATION NAME OP INSURANCE COMPANY OR ASSOCIATION 2759. DALLAS. TEXAS 752; DATE- *~^y. SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF'eMPiWr lS5Dc A-6! TO U.S AND S Jant SIGNCi * -TK: RETURN THIS NOTICE TO:.. ,, K1_rt TEXAS EMPLOYERS INSURANCE ASSOtWwWR ANCE DO NOT MAIL TO INDUSTRIAL ACCIDENT HOARD. bk 11-13-74 02-1090 TITLE OF PERSON SIGNING NOTICE SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF Of INSURANCE COMPANY 7.50 ORIGINAL COPY - -- :e1. DALLAS, TEXAS AUTHORIZED REMEtEXTRTIVE TEfA 3530 UO-l-SO INSURANCE DEPT* * DIVIDED RISK ENDORSEMENT - TEXAS Pm TX-2 <10-1-54) It is ngri-eil that; 1. Such :nu-iincc it* is afforded by the policy by reason of the designation of Tera* in !(em J of the declaration* ^ !oe* not apply to injury, including death resulting therefrom, sustained ir. the operation* specified below, and "remuneration**, when used as a premium basis for such insurance, shall not include the remuneration of em ployees engaged in such operations. 2. Nothing in this endorsement shall reliese the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in which the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer: All operations required under the insured's contract with Dow Chemical USA Texas Division, an operating unit of the Dow Chemical Company (DCW); which specifically states that Dow procures the insurance coverage specified in the contract, Otbr operations. Including operations at the Named Insured's regularly established main or branch office, factory shop, warehouse or similar place are not excluded. This endorsement does not apply to any executive officer, partner , or sole proprietor covered under Endorsement TX-3.2 attached to this policy. This endorsement shall be subject (o all ot the provisions end conditions ol the Policy, end nothin* herein contained shall vary, alter v extend any tara, pro vision or condition cl the Policy except as herein specifically stated. This endowment, when signed by a duly Authorized Representative at the Company shall lor* a part ot policy number A-63910 TO Cert. No. C-63910 issued by the TEXAS EMPLOYERS* INSURANCE ASSOCIATION ol Dallas. Texas U.S. Contractors* Inc. AHO SMALL BE EFFECTIVE ON January I, 1975 SIGNED at DALLAS, TEXAS received INDUSTRIAL ACC. % ,!v i - at the sane fcout of said data as the hour of day provided by the fVicy for cosstactPlod, and (his endorsement shell teunnete with the Policy. S rS AUTHORIZED WMCKiTATlVt TE1A 3530 (10-l-S<) INSURANCE DEPT* /? ?s-0o Commission No. 5292_________ Endorsement No. 3u-l< 1 It is agrssA that tbs following is hm3qr slinrinstgig Tran ths Schadul* of miflors--snt #3, Item XX-3*2: All Aetitw Ezscutlvs Officers RECEIVED INDUSTRIAL ACCIDENT BOARD SEP 475 I rt INSURANCE DEPT. This endowment shall he subject to ail of the terms, provisions and conditions of the Policy, and nothing herein contained shall vary, alter or e\timd any term, provision or condition of the Policy except as herein specifically stated. This endorsement, when signed by a duly Authorized Representative of the Company shall form a part of poucV~numbfr D-6150S CERTIFICATE NUMBER ISSUED BY THE ~ Texas EmPLOYeRS* inSURance ASSOCianon of Dallas, Texas S Contractors, Xae* AND RHAl.L BE FFFfCTIVF ON .o*tf Jsnnmry 1, 1975 SKVifti AT Dnlh's. 02-1090 nr Texa1s/20/75 at the same hour of said date as the hour of day provided by the Policy for commence ment of the Policy Period, and this endorsement shall terminate with the Policy. ...................... ... * I BY * *" AUTHORIZED REPRESENTATIVE Cow*, wo. 559 DIVIDED RISK ENDORSEMENT - TEXAS #20 TX.J (100-54) ft m Birr'd thmt; 001 !a-v I Socli lnwurmnce as is afforded by the poticy by reason of the detiignotion of Texas in Item J of the declarations does not apply to injury, including death resulting therefrom, sustained in the operations specified below, and "remuneration", when used as a premium basis for such insurance, shall not include the remuneration of em ployees engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in which the Texas operations described in the declarations are conducted: Operations in the business described in the declarations but covered by the policy of another insurer; "All operations retired under the lnsurtd's Contract with Dow ChwdLcal U.U.A. Texas Division1 an operating unit of the Dow Chemical Company (ECW)j which specifically states that Dow procures the insurance aoversees specified in the contract. Other operations, Inc:tiding operations at the Earned Insured's regularly established or branch office, rectory, atapp, warehouse at elsdlar place ere not excluded. This endorsement djea not apply to any executive Officer, partner or sole proprietor covered under Endorsement Torn IX 3.2 attached to this policy. It is further agreed that Endorsement #2, Divided Risk Endorsement-Texas, and Ehdorse&sant #6 are hereby eliminated from this policy. This endorsement shill be subject to ill of the terms, provisions ind conditions of the Policy, md nothing hen visin' or condition of the Policy except is herein specKIcilly stated. This endorsement, when signed bye duly Authorized Representative ot the Compeny shill form a part ol POLICY WUWiiSR A-64077 Cart. #B-64077 Issued by the TEXAS EMPLOY1 Monies! & Rea extend Joy term. pr n, Texes A NO SHALL BE ErFECTiVE OM (dot*} August 21,1974 SIGNED AT DALLAS, TEXAS -Qg-1000 an. 9/a?/7h- = n-~=. TTIA 1530 (to-1-54J ------------ - it th sin* hour of Mid datt at th hdfTof day providid by th Polity for cqMC9nnt of lh# Policy Puled. and this *Pdorssn! shall terematt iUt the Policy. . --~=J Aumotuto mtrram ------------ . NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER ' UXAJ WOKKMEHtfiSMPeHtATIOM ACT' f /}() EMPLOYER: urrimf* irf fvm ond ramplxtp rn&Eeq odd.-***, rcvectd by tbit pofcy under wfwck or*ut*yn of* r nM*^***! * f**<x AhocK orty n*< vKW'f ndortm>nh ) __U._S^Contractors, Jnc. B0089568----------------- -------------------------------------------------------- ------------------------------------------------ ADDRESS- ** 0. Bx 3337 I*X yTorfraon^ TX 77566 ___________________________________ LOCATION OF RISK: 13 ENTIRE STATE OF TEXAS DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY POLICY NUMBER B-63910 NEW POLICY H RENEWAL EFFECTIVE DATE t2:0t AM 1/1/74 CANCELLED K! EXPIRES AT 12:01 A.M. ON l/l/75 INSURANCE CO. TEIA APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annuol Employment:_____ B. Seasonal Employment by Month: JAN. FEB. MAR. APR. MAY JUN. c cp> SEP. OCT. NOV. DEC. OCCUPATION Oil or Gag AQT OR BROKER ADDRESS CITY STATE ZIP Notice is hereby given by the named employe! and <he i.amed insurance company, os required by the Texos Workmen's Compensation Insurance Act Chapter 103. Genera? laws. 1917. and amendments thereto that the above named employer has become o subscriber under said Act od amendments thereto ond provided tor the payment of compensation to employees under the terms and provisions thareof Any employer or association wilfully or refusing to file this notice sholl be hoble for and shall pay to the State of Texas q penalty of not more than One thousond Dollars (il.0001 for each offense. Com* 559S It in *#reed that: 1. Such insurance ns i afforded by the policy by reason of the designation of Teios in Item 3 of the declaration* dors not apply to injury, including (tenth resulting therefrom, sustained in the operations specified below, and * 'remuneration", when used as a premium basis for such insurance, shall not include the remuneration of em ployees engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation J aw. OPERATIONS EXCLUDED: l. Operations in a business separate from the business in whch the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer: "All operations requiring labor at or Ann premises owned, operated, or leased by the Itow Chemical Company, Texas Division. Other operations, including operations at the Named Insured's regularly established main or branch office, factory, shop, warehouse or almiliar place are not excluded. It is further agreed that Ehdorsements #2 and #4 are hereby eliminated. In.': wndorseatent shall be subject to all of the terns, provisions and conditions ot the Policy, and nothing herein conlained shall vary, alter or extend any tern, pro vision or condition ;! the Policy except as herein specifically stated. This endorsement, when signed by a duly Authorized Represenlativ. ot the Company shall torn a part ot POLICY NUMBER A-63910 Cert. # B-63910 TO U. S. Contractors, Inc. '" -------------------------------------------------------------------- ------- -- .. _ issued by the TEXAS EMPLOYERS' WSURAHCE ASSOCIATION ol Pallas. Teats AND &KA`_L PE EFFECTIVE ON (data) August 9, 1974 SIGNED AT DALLAS. TEXAS 02-1090 nr Q/l&fTh Tf'lA 3530 ( 10-- 1--54) at the same hour of said date as the how ot '*-/ v raided by the Policy lot coenc*ment of the Policy Period, and this endorsement shall laminate **h the Policy. ay --r -- AUTHORIZED REMeSfUTATH* mn it that* ' \)(s i. >"'iirh insurance as is afforded by the policy by reason of the designation of Texas in Itemn of the declarations docs nor apply to injury, including death resulting therefrom, sustained in the operations Specified below, and ''remuneration", when used as a premium basis for such insurance, shall nor include the remcneration of em ployees engaged in such operations. .2 Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in which the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer. Alt wyilwi wait* Hm hwrilti wrtnn with Nv CSwi--1 nt tM HvUiw, m <rnliK| Ut of etw Atm chwinl Coopoap (BOU)| ktdk UMifiMlIy Mlw Mwt Iw ftiwrn Ik* mmnp ipaalfM | dw MtlrMI, Ottrr UtMliti t tha Km< Usmi'i nfilntjr mitttifcii sate or Wmli alilM, Ismjf, htf, wwihwai ot ilslUr plooc or* wet ial>i4. 1M wdmwst Amo m eppljr to ap omltn iff^wr, porOwnr, or pnfitleter eawnd ooior aoiwron--t TX3.1 ittaM to tiki* paltej. tt to hntor <mi< dWI toiniwwi 111, PMiei IUI totmtoMl* Tcuit to towly *Ubutoi. This endorsement shall be subject to >11 of the terns, provisions >nd conditions of the Policy vision or condition of the Policy except as herein specifically stated. This endorsement, hefc^|)|p|(l by^uly Authorized Representative of lha Company '-tmm B45tl0 S. Cntrccton, toe. confined shall vary, alter or tx'efld toy hm, pit> URANCE ASSOCIATION Of 0*U*s. Tius "TOJfclFWriW SIGNE.0 AT M.l23 DALLAS, j^J2.y.. TEIA 3530 (10-1-54) as the hoof o( day ptovtdad by Policy for Penod, and this en<Joise*fnt shall laminatt with tfn Policy. 0Y V 'y/s - *UtK0irtB tMt:trUTr*t 'VySl Inwumnrp ( <rrmii*ion No. 5-I-7J roue* maximum Et i VMd ttakt tta* Selley Krloft At tbm X. f ttM fellejr t* hnwbr aer>dBdt to mil Jun 15, 1973 to JSoutry X, 197*1 Endorsement. No._ <# tbO This endorsement shall bo subject to all of the terms, provisions and conditions of the Policy, and nothing herein contained shall vary, alter or extend any term, provision or condition of the Policy except as herein specifically stated. This endorsement when signed by a duly A jTTniJ^vjWtojitGagntatiye of the Company shall form a part of policy" numbfr FICAT6 NUMBER Df/j/tft AatiS9M___________________ TO Texas EmPLOTOF Ooil 103S. inBURance ASSOCtanon of Dallas, Texas #*SffrAV4973--------------- |as the hour of day provided by the Policy for commence* ' this endorsement shall terminate with the Policy. Dallas. Ti-xns -. 02-1090 nr 6/6_/7S*...... /?& 3e> Insurance (*<.m*nixui<*n No ft Endornemrnt No. It la agred that Item 2 under OPSMnOHS gCCUJPCP Of th Divided Risk fitdoraenent #2 attached to the declarations of the Policy to which this endorsement la attached la encoded to read* "All operation required under the insured'a contract with Dow Cheadcal U.S.A. Texas Division, an operating unit of the Dow Chemical Company (DOT), which specifically states that Daw procures the lnausnce coverages specified in the contract. Other . - -tiona, including operations at the Vased insured's regularly established naln or branch office, factory, shop*-- warehouse or similar place are not excluded.1 nC rp yti Thin endorsement shall ho subject to nil of the terms, provisions and conditions of thetWWjTand nothing herein contained shall vary alter nr extend any term, provision or condition of the Policy except as herein specifically stated. This endorsement. when signed l.y a duly Authorized Representative of the Company shall form a part of POU'CV NUMBfR A-63910 CERTIFICATE NUMBER IS^tlFO I3Y THE Texas emPLOYens* msuRance AssaciaTton of Dallas, Texts U.3. Contractors, Inc* ANO'SHALL eV T f F I v I * I ON April 1, 1973 510NFU AT rialb*'. Tevjt'S 7-17-73/gr 02-1090 at the same hour of said date as the hour of day provided by the Policy for commence ment of the Policy Period, and this endorsement shall terminate with the Policy. ' I BY " ' *""" *' ' _______AUTHORIZED REPRESENTATIVE .4 <***'*} *?.-< * ." O. H t'4 K.z*ri?T. >~~2. ADDRESS: !'ox 1537 Lake J.'ickson .Texas V?566 LOCATION OF RISK: ENTIRE STATE OF TEXAS X3 DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY Sec endorsement attached. POLICY NUMBER ErrECTIVE DATE !2:0I am CANCELLED INSURANCE CO. WC-A-63910 S NEW POLICY April 1.1973 TKIA RENEWAL El EXPIRES AT 12:01 A.M. ON January 1, 197k APPROXIMATE NUMBER OF EMPLOYEES: Cl A. Stable Annual Employment? B. Seasonal Employment by Month: iAN. FEB. MAR APR. MAY JUN. -------- JUl. AUG. SEP. OCT. NOV. DEC. Oil or Gas KX -Refining OCCUPATION ACT. OR BROKER ADDRESS CITY STATE ZIP Notice is hereby given by the named employer and the named insurance company, as required by the Texas Workmen's Compensation insurance Act. Chapter 103. General Laws. WI7. and amendments thereto, thot the above named employer has become a 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 association wilfully failing or refusing to file this notice shall be liable for and shall pay to the State of Texas o penalty of not more than One Thousand Dollars ($1,000) for each offense. EMPIOYER SIGN insurance company sign here SIGNED:. *~2). S7Ja?u.<utf nTf- S-ec. ** T/z/aoj <X/W. TITLr oe PERSON SIGHING NOTICE TV- industrial! l*.-n-rh r, 7 07 3 TEXAS EMPLOYERS INSURANCE ASSOCIATION NAME OF INSURANCE COMPANY OR ASSOCIATION 1 BOX 2759. 0ALLAS. TEXAS 75221 ADDRESS SIGNATURE HERF CONSTITUTES NOTICE ON BEHAlf OF EMPlOVEll NOTH: RETURN THIS NOTICE TO: C i DEEX.TEXAS EMPLOYERS INSURANCE ASSOCIATION INSUF AMf DO NOT MAIL TO INDUSTRIAL ACCIDZnT'Y^ HOARD. TITLE OF PERSON SIGNING NOTICE ---iiIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANY 02 $7.50 CG 3-14-73 IAI I.. 101*1 T(IA JOU 0 111 <N ORIGINAL COPY DIVIDED RISK ENDORSEMENT - TEXAS (10*1-54) It in mgreed that: 1. Such insurance as is afforded by the policy by reason of the designation of Texas in Item 3 of the declarations does not apply to injury, including death resulting therefrom, sustained in the operations specified below, and "remuneration", when used as a premium basis for such insurance, 'hall not include the remuneration of em ployers engaged in such operations. 2. Nothing in this endorsement shall relieve the company or the insured of obligations imposed upon them by the Texas Workmen's Compensation Law. OPERATIONS EXCLUDED: 1. Operations in a business separate from the business in which the Texas operations described in the declarations are conducted: 2. Operations in the business described in the declarations but covered by the policy of another insurer All operation* requiring labor at or from preala** owned, operated or leaaed by The Dow Chemical Company, Texas Division, other operations. Including operation* at the Mamed Insured'* regularly established main or branch office, factory, shop, warehouse or similar place are not ex* eluded. This endorsement shell be subject to ell of the terns, provisions end conditions o( the Policy, end nothing herein contained shall vary, alter or extend any tarn, pro vision or condition of the Policy except as herein specifically stated. This endorsement, when signed bye duly Authorized Representative of Ihe Company shall form a part of WUICV HUMBER WC-A-63910 TO Issued by the TEXAS EMPLOYERS' INSURANCE ASSOCIATION ol Dallas, Texas U,S* Contractor*. Inc. AND SMALL HE EFFECTIVE ON frf#f#j April 1, 1973 SIGNED AT D-U-73 DALLAS, TEXAS at the sama hour ot said date as the hour ol day provided by the Policy lor commencenent ot Ihe Policy Period, and this endorsement shall lerminite with the Policy, JSV ^^ AUTHORIZE!) REFRCSERTMTK TE1A JSSD (10-1-50 EXECUTIVE OFFICERS ENDORSEMENT - TEXAS #3 TVU f.VJ.V/57) * li is agreed that: 1. The insured being a corporation, such insurance as is afforded by the policy by reason of the designation of Texas in Item } 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 are designated below or in Item A of the declarations. 2. `'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 All active executive officers This endorsement shall be subject to all of the terns, provisions and conditions of the Policy, and nothing herein contained shall vary, altar or extend My tern, pro vision or condition of the Policy except as herein specifically stated. This endorsement, when signed by a duty Authorized Representative of the Company shall form a part of POLICY NUMBER WC-A-63910 TO Issued by ttie TEXAS EMPLOYERS' INSURANCE ASSOCIATION of Dallas, Tm U.S. Contractor*, Inc. . AND SMALL BE EFFECTIVE. ON (df) Aoril 1. 1973 SIGNED AT p.o. Box 1337. Lake Jackson. TX 77566 at the sane hour ol said data as tfis hour et day provided tr t the Policy for commencegent ol the Policy Period, and this endoisawnt shill (ruinate with the Policy. BY 3-14-73Dollos, Texas T C I * i 7*3* V ___ autnobiho Kmtimarwc NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER -19765 TEXAS WORKMEN'S COMPENSATION ACT .... EMPLOYER: </*ti**e in if* n* ftl cswalrlr vtn tNmMHh > Mittit. (otf*l fcr ttl| Mlitr lP*w Wt* #tflOAI ( in Ttwt auk* *V nm. U. S. CONTRACTORS tNC. ^ _ _____________ ________ ______ ___ MG NI CAL & POWELL^ INC^ MONtCAL & REA., L.L. MON I CAL, HJH. MON I CAL AND E. C._RF.A_,_ PARTNERS; ' MONWELL MATERIALS, I NC. "____ ADDRESS; p-*,, B0X 338, LAKE JACKSON, _TEXASL 77566-/ , c' LOCATION OF RISK K) ENTIRE STATE OF TEXAS '4 DIVIDED RISK -- EXPLAIN OPERATION COVERED BY THIS POLICY POLICY NUMBER EFFECTIVE DATE !S:01 AM CANCELLED 1613 03 033490 OCTOBER 1, 1972 NEW POLICY | RENEWAL RQ EXPIRES AT 12:01 AM. ON INSURANCE CO. EMPLOYERS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN OCTOBER 1 , 1973 APPROXIMATE NUMBER OF EMPLOYEES: A. Stable Annual Employment: 341 B. Seasonal Employment by Month: __ JAN. _ *E0. MAR. APR. MAY JUN. JUL. AUG. SEP. OCT. NOV. DEC. OIL OR GAS OCCUPATION AOT. OR BROKER ADORES* CITY STATE ZIP Notice Is Hereby given bv the named employer and the named insurance company, as required by the Texes Workmen's Compensation Insurance Act Chapter 103, General Laws. 1917, and amendments thereto, that tha above named employer has become e subscriber under said Act and amend ments thereto and provided (or the payment ol compensation to employees under the terms and provisions thereof. Any employer or association wilfully failing or refusing to file this notice shall be liable for and shall pay to the State of Texas a penally of not more than One Thousand Dollars (31,000) for each offense. EMPLOYER SIGN HERE ! INSURANCE COMPANY SIGH HERE Hi EMPLOYERS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN ' OATF- TITLE OF PERSON SIGNINQ NOTICE_ 1 'TRDOsrR). 7/W erA,raT?i?Ti?^w,Aroc,`T,oN DALLAS. TEXAS 75247 ADDRESS sirnfii- {jfyj&k&LS SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER NOTE: RETURN THIS NOTICE TO: (EMPLOYERS MUTUAL 1 IA3ILITY INSURANCE COMPANiflflfcjl WISCONSIN , DO NOT MAIL 70 INDUSTRIAL ACCIDENT BOARD. * I.A.8. Form 20-69 (Rev. 10-1-691 ORIGINAL COPY TITLE Or PERSON SIGNING NOTICE HERE CONSTITUTES NOTICE ON BEHALF OF INSURANCE COMPANT 1 # - n 7 NOTICE THAT EMPLOYFrHMBECOMFSUlSCRIBER OO'J Si raw wowwort compehsaton act / / /><: '<>' EMPLOYER: HrcMt til (rn Mtfi, m4 tw**W# tul!ii rttfmt. covt'ri %y H *e? w<*r un ) fmNoM $n in Trut AUtth *Tf mc U. S. CONTRACTORS. INCM3HICAL & POWELL. INC.; __ MONICAI. ?t REA., I.. L. NPKICAL, H. H. MIMICAL AND E. C. REA, PARTNERS.__________ _________________________________________ __________ ADDRESS: P- 0. BOX 278, IAKE JACKSON, TEXAS 77566; LOCATION OF RISK ENTIRE STATE OF TEXAS S DIVIDEDJRISK -- EXPLAIN OPERATION COVERED BY THIS POLICY ~ j5t^RATI0f{C-"A_T UNION CARBIDE PIAHT COVERED UNDER 'gOi'ICY NUMBER 1(512-0^-033490 . TEXAS. EMPLOYERS .POLICY _D-58lOO,_____ _______________________ EFFECTIVE DATE IttOI AM 10-1-71 CANCELLED INSURANCE CO. EMPLOYERS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN NEW POLICY RENEWAL Kl EXPIRES AT 12:01 A.M. ON ____ IP.TMi.. APPROXIMATE NUMBER OF EMPLOYEES: / A. Stoble Annual Employment: 34l______ B. Seosonol Employment by Month: JAN. FEB. MAR. APR. MAY JUN. JUL AUG. SEP. OCT. NOV. osc. OIL OR GAS-REFINING. DISTILLING OR COMPRESSING UNITS. OCCUPATION ACT. OR BROKER Notice is hereby given by the named employer and the named insurance company, as required by the Texas Workmen's Compensation Insurance Act, Chapter 103, General laws, 1917. and amendments thereto, that the above named employer has become a subscriber under said Act and amend ments thereto and provided for the payment of compensation to employees under the terms and provisions thereof. Any employer or association wiiti/lly tailing or refusing to file this notice shall be liable for and shall pay to the State of Texas a penalty of not more than One Thousand Dollars ($I,000| tor each offensa. EMPLOYER SIGN HERE SIGNED: INSURANCE COMPANY SIGN HERE EMPLOYERS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN ' 77W"awoc.at,,5T DATE: TITLE OF PERSON SIGNING NOnCfffrm, Detllas. Texas 75247 L SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF Of EMPLOYER tyi ?J?7f SALE COORDINATOR NOTE: RETURN THIS NOTICE TO: EMPLOYERS TITLE OP PERSON SIGNING NOTICE 1IA,MUTUAL LIABILITY INSURANCE COMPAfifitSL/l WISCONSIN f'fCE DEp^natore here CONSTITUTES notice DO NOT MAIL TO INDUSTRIAL ACCIDENT BOARD. VR BEHALF OF INSURANCE COMPANY I.A.8. Fot*n 20-69 t*ev * 2**e 1 10 > ORIGINAL COPY NOTICE THAT EMPLOYER HAS BECOME SUBSCRIBER .37U&S. EMPLOYER: Nry *R int **. *4 mWrj ___ U. o. Contractors, Inc. twr?< ty (Mi #> *<tr *Wt* Mtrrthw v* cs*4*tl ta Tim. / ADDRESS: Box 101? _CIute, Texas___ 77'?31 LOCATION OF RISK: ) ENTIRE STATE OF TEXAS DIVIDED RISK ~ EXPLAIN OPERATION COVERED BY THIS POLICY POLICY NUMBER effective date 12:oi am CANCELLED l6H-.00-Q5.k223________ 10-1-70 NEW POLICY RENEWAL 0 EXPIRES AT 12:01 A.M. ON INSURANCE CO. EMPLOYERS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN October 1, 1971 APPROXIMATE NUMBER OF EMPLOYEES: 25 A. Stable Annual Employment:-------------------------B. Seasonal Employment by Month: JAN. FEB. MAR. APR. MAY JUN. JUL. AUG. SEP. OCT. NOV. DEC. Oil or Gas - Refining OCCUPATION -Ffrrplnyip.rfl Ins, of Wausau..... 770Q. ..Cwpe.n.tg^ AOTTon Bfi Texas 75247. Notice Is hereby given by the named employer and the named insurance company, as required by the Texas Workmen's Compensation Incu.-ance Act amendChapter 103, General laws. 1917, and amendments thereto, that the above named employer has become a subscriber under said Act and ments thereto and provided (or the payment of compensation to employees under the terms and provisions thereof. Any employer of association wilfully (ailing or refusing to file this notice shall be liable lor and shall pay to the State of Texas a penalty of not more than One Thousand Dollars ($1,000) (or each offense. EMPLOYER SIGN HERE SIGNER- yTl OyXA.-C<rJ^ t/f CC? i7~ TITLE OF PERSON SIONINO NOTICE > INSURANCE COMPANY SIGN HERE HHflHI EMPLOYERS MUTUAL LIABILITY INSURANCE CO. OF WISCONSIN Enrolovers Insurance of Wausau NAME OF INSURANCE COMPANY OR AMOCIATION 7700 Carpenter Frwy, Dajlas, Terns RETF- SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER NOTE: RETURN THIS NOTICE TO: EMPLOYERS MUTUAL LIABILITY INSURANCE COMPANY OF WISCONSIN DO NOT MAIL TO INDUSTRIAL ACCIDENT BOARD. IA.B. Form 20-69 <Rv. 10-1-691 < Stl.2*6 t 110,11) ORIGINAL c v- x> v V dales CoordS fmtoV _\\ ^ TITLX UA PtfON lOMINa KOTJM \ SIGNATURE'H'ESE-.CWiSniiBS^twCE ON BEHWT.Of lJiaiRANfiE COMPANY