Document pmvRaG85xRgYgG18bYmn7pYxw
Y
LEONARD W. RILEY, JR. EXECUTIVE DIRECTOR
TAMPERING WITH THIS LABEL NULLIFIES THE CERTIFICATION
TEXAS WORKERS' COMPENSATION COMMISSION
SOUTHFIELD BUILDING, MS-96,4000 SOUTH IH-35, AUSTIN, TEXAS 78704-7491 (512)448-7900
STATE OF TEXAS COUNTY OF TRAVIS
CERTIFICATION OF SPECIFIED INSTRUMENTS
I, Rachel Solis, Data Entry Operator and Custodian of the Records of the Texas Workers' Compensation Commission of the State of Texas, DO HEREBY CERTIFY that the attached are complete copies of the IAB Form 20s' (Notice that Employer has become Subscriber) and the IAB Form 9 (Notice of Cancellation of Compensation Insurance) for the period of01-05-77 to 01-05-80 for:
Pontiac Refining Corporation and
Union Pacific Resources MBI#937952100
I FURTHER CERTIFY that I am the lawful possessor and custodian of the records of the Texas Workers' Compensation Commission of the State ofTexas.
IN TESTIMONY WHEREOF, I have officially affixed my name and caused to be impressed hereon the seal ofthe Texas Workers' Compensation Commission at 4000 South IH-35, in the City ofAustin, Texas on this 5th day ofFebruary, 2001.
"This document is signed under the authority delegated to me by Leonard W. Riley, Jr., Executive Director, pursuant to the Texas Workers' Compensation Act, Texas Labor Code Sections 402.041-402.042."
Rachel Solis, Insurance Coverage Department
Tex. Lab. Code 402.042,402.081. Do not remove any of the records or detach this certification page. These actions nullify the certification.
An Equal Opportunity Employer
,tU,om#d*wJfcyi/E5twttrn*tvto&h* wife1 **$ Acfttniwi
$3*kt fitoUUdlieiH# |MyrH*nf t aiwp*rt**iIon to fa0toy-- ornkf th* f*ttt cw4 pwUkK** ft<of. Any <npfo>vr ** ottoetetfo*
$*j&$"ai"Vi^ftJtilLne. klo u<mu iftH ,NKAttfc^k* thf*atnl iba* IllloflbliUl* lt<oirf manwd4 ithMalIl pwowy iKa> <hhA* tSMbH<** *oAf TTaamnac* ao apomnmoIlmfy noff Mnoll mmoorn* f(hba*rnt OOnn** TThhowurCtoanrxdt Oofkttf '(lITl .ntrMiftVO1 ).';.-- vw'^fij
l^Vaocho*^
,
. ..
^AH
Sifi i LNSUTAWC* COMPANY SIGN HIM isd'not vu onoun nami
37 ?<TJ /
Sp5r`
ffe
tmitmtvmsr iwawAWCEAssooATioH
OFWSOIMHet COMPANY OtAtSOCMIUN
IX 2759, PAUAS, TEXAS i
POLICY NUMBER:___ Hr.r-Ar-73863.
r */*t.*vV, i't,J'vj.lCf''Tit**l$SGj'aItPs
S NEW POLICY
... v-JUffi&iSA
ME IU% JE CONSTITUTS&TnOTICE ON
,NCE COMPANY.
^auiul<!UU4(a..
EFFECTIVE: FROM -2t5-p79..
fc; -.?.# -
'^ri' :*'
to.imSA80^;...',.;^-i
A&ORESS IMMEDIATE PRIOR COVERAGE WAS IN EFFECT FOR PERIOD FROM:-
THROUGH: (INS. CO.) TF.TA________________ (NOT MOUIitCO V IttNCWtO <N tAMt COMPANY)
___g
TO: POUCY NUMfiER*
.. . pBSRtTOSHE
...................... ... .
>
SCOPE OF COVERAGE; 53 ENTIRE STATE Of TEXAS (ALL OPERATIONS)
BOARD'S STAMP -
53 PROPRIETORAND/OR EXECUTIVE OFFICERS INCLUDED
Ig-v
-> a NOTICE: FOR DIVIDED RISK POLICIES COVERING SPECIFIC ' - JOBS. JOINT VENTURES AND FOREIGN OPERATIONS MUST BE
. FILED ON I.A.B. FORM .154 ' . a R6NSTATEMENT: REVOKES CANCELLATION
EFFECTIVE
^^eOCCUPAITON OF,.:
IIRv.: "'"INSURED; OIL Refining.
RECEVSO
' WK2979
- . fe&Bfrfal Accident
||tl|
K?*AFPROXlMATE NUMBER
iJj&^^BtoOVEEfc S.SQfi
'"''I^^.BTIMAtED ANNUAL
________________
s^lrn;
'
isi--'ii^.$i'PAYROLL: ------------- 16t7flftt9fi0.__________________________
-.
ifl^Cfl-BElOW: UST PRINCIPAL CORPORATE:NAME' F|RST( GIVING
I'S&v;' V'HEADQUARTERS 'ADDRESS: THEN L1$r EVERY SUBSIDIARY '.^.-"CORPORATION DOING BUSINESS IN TEXAS AND PROVIDE ITS
.'PRINCIPAL TEXAS ADDRESS. ALSO1 LIST EVERY OPERATING
ffiS'l-i*-5,= ** DIVISIONAL NAME USED. IN TEXAS AND PROVIDE THEIR
^ S3.LOCATIONS. CONTINUE UST ON SSAMATE SHEET ANO AT- j...
y.
i^g^^phaaplla P*troXtiiaJtfDapaay-i~CjLnqt%~Flpe' Line -----
jjCoBpany',- a wHolly-;<awaady.8ubgldi*Tff^f-Chaipl.ia '
.jffC^'Batcolaw Cogpany:;:; Union.. ?ao-if4-G--&o oougcea
'rrm
i - . 1r
1 n i - i_ap.rjTl 11 J ft,11 J-
.sAj " ? . .`V''v' jiV i^, K.vv`''AIvA-.
im*OP fBUON SJOKMO KOTOE
DAT^EV' T., > S&MATIHt&'KEftS .CONSTITUTES NOTICE OT^ SEHALf' QF-^rt
^UiUDlMUW.lillM...
^^^^HArgafefaipfag-iCGiBRto^l-a'P^ntip-Refliti^riS^Ptf ^^rfecogpor-At tom.; <^plio:-geaoeHeiiipljB-|-
Ci-TZ:'. ">.
` ~1
.mrw..- mm 's',,-- .. <...<>.
>. - ;'r_. <-
. *f.L ..'"`V'l r .,.{fji" * f V ..
l . R|-
CP. ?i . c>.:
*" .ln7C,
fy Texas*-' :1'.
Vy
r *fc
A*
sssf^-a'v'vv
....for.. fh* M^,v,,m,,.M..i e,,A. ronw_o__w__U__c_n__t-o *motov*9*_&__*.-.-_A___*_f_t_r_m__t_'&__W__ rp_r_o_v__W__o_n__t_f_h_t_f_t_fo__f_r_A__n,ys_^_m__p__to_ytr or oiivurioilonwilfud
rnw^iy^S^nfaticrQ fa |||a ihii nolle* cnoll bo lloU lor and Hull pay. lo th* StotaoT Toxat.O pondli* at not rmsfO'-iHwn Ono'Tbowohd-pii'
S'g-jJtu^orycifi ottortw. ^.siv*TiAf *,**tm,m '"**....1
USs:-1? JNSURAfK* CWMPANY^ipN HttE
k
` (DO HOT U$(C400? NAME)
It^SPvf
r'
.. *'
I5\ -.-v *#.%>}> '
gS*v
TEXAS awtovag1INSURANCEASSOCIATION
,j<*aiKsunMKco*nr*KroA-------------
B0X^7S9, PALLAS;-'
POLICY NUMBER:______ H&oA~?683S NEW POLICY
BV-vlCS)
' '*-08La cmwmwa^^mI
;za
MATURE HERE CONSTITUTES NOTICE ON BEHALF OF USANCE COMPANY.
EFFECTIVE: FROM-
-2r5-79 TO. -i*s>ao^u^ .' '%.- il
NAME
ADtefit IMMEDIATE MtlOft COVERAGE WAS IN EFFECT FOR PERIOD FROM-
THROUGH: (INS. CO.)
THXA
{NOT KQUfttO * ttNtWtO IN IAMI COMTAKY)
mv *s&.- V
.SCOPE OF COVERAGE:
QtENTIRE STATE OF TEXAS (ALL OPERATIONS)
C5LPROPRIETOR ANO/OR EXECUTIVE OFFICERS INCLUDED
. . NOtICE: FOR OtVtOEO RISK POLICIES COVERING SPEOFIC JpRS. UOINT VENTURES AND FOREIGN OPERATIONS MUST BE /FRED ON LAJL FORM 1ST O REINSTATEMENT: REVOKES CANCELLATION
: EFFECTIVE
OCCUPATION OF_ , _
,
MButn-
OH. Btfitllug
APPROXIMATENUMBER -OF Miwewm-
.ESTIMATEOANNUAL PAYROLL:
10,700,900.
TOt POUCV NUMftERt
fHO^CWMMC*
BOARiySSTAMP
J
'
j....
heotwsV' AUSTIN-:
=
1
V met
' ,.ij Jiir.TS ii-'i V *1 *' * V,';.!1!
.. *"i.'.'.'5?'.y
. ...BELOW: LIST PRINCIPAL CORPORATE NAME FIRST. QtVWO ^jHEAOPMARTERS ADDRESS; THEN .LIST EVERY SUBSIDIARY
feAV- - r;`CORPORATION DOING AUStEIESS IN TEXAS AND PROVIDE ITS . .
g-&?--:i?!'pRINClPAL TEXAS ADDRESS. . ALSO -LIST -EVERY -OPERATING . ttVBtONAL NAME USED 4N- TEXAS AND .PROVIDE THE* " . '
l^gj.%sUX>TlONS. .CONTINUE UST ON .ffPARATE SHEET AND AT-
~i
^&fA%RCH. ^
i'f~ .,-eyf3
Cbaaplta Ptr<&idli
CaIbetP';
raucetmo* sgmno otw
"Ftpo Ilna
POT
tgy DATE:.
of Chnaplla gitr61iai' (
: SWHAIURE K CONSTITUTES NOTICE ON BEHALF-Of^7
' Paalflc ^wkwrtfwi
:empwyv;;'-,-- ;
. .-.
.
.gtttaoaR^liSl*--ri-3--S--5--3-S-->--5-]-C--i-r-o--n--i-t-&--^-a--j----
txt >" RF*'v~5**V- __ ukArni- r
1 './.'"j;1 . !- * v. V ,, ' ' _v" 1 "* 1
ianpfNpf
............ JMlkM
""
Ip&O*^ ' ^';
T ' - >#"':&&
* INDUSTRlAtACdDEMT feOARD ` P.O. Box 12757. Copilot Station
AUSTIN, TEXAS 78711
' Th Industrial Acddent Board I* hereby given notice of the CANCELLATION OF A POLICY of Insuranee.Usiiid.
..
under the term* and provision* of the Texas Workers' Compensation law, to
/
Chtxplln Petroleum Coetpsny fc/or Calner Pipe Line Coerpany, a wholly owned
rt'
fmplovfr of Chastnlto Petroleum Compear fc/or Union Pacific Beaonroea Corporation t/etr.geYLwi-
Serriet Station*, Inc, &/or Cn^iifrCsrtht^f^YJe^ie^^A^Pontlxc Refining Corporation */&*;
ADDRESS__ L. , ~'t% ^^^(P.O.^||iirjr$U'eet Addfess)
(City. Stole, ZipCode)
t.
OCCUPATION.. POLICY NUMBER..
.^
(Character of business in which engaged)
"C-a-"898 -PCH1CY maao,
wt
T,, 1-5-80
OATE OF CANCELLATION__JfaBru*ry_5___ ,9_1?_. HOUR OF CANCELLATION.
(Month and day)
OATE NOTICE MAILED TO SUBSCRIBER Being rewritten___________________
INSURER. ADDRESS.
Texas emPLoveRS' insunanca Asaocianon
(Full nom* of Inturance company or atiociolion)
BOX 2759, DALLAS, TEXAS 7S221
(P.O. &ok or Street Address)
(City, State, Zip Code)
12:01 A.M.
(Hour) (A.M. or P.M.)
, >< rj
* '1V&V
By- Q. a^r^. (NaAn and official copodty) Joseph A. Boone
fern-
*Chaplim8 Petrochemicals,. Inc. S/or Ctunplln Trading Cospany
Mgg|
BOARD'S STAMP, .
:~RECE|VD-wf1S$
...V-fj, ..
'.'s-.vi
'I MiA'iRin`^1o97W9rt1
5'
lV''^5^ 8
l&SrS^eetdcl <*t______
SS'i
" (No"1* of city or town)
g&Y*s.: :'
..-SO*
* " A* '
' *C**&
LnjS1:
g. AnnBfss.. g*0, ga 55a. Eaidt _OKlahoaft_
'im - ,m'l/HV.vy< I-- ....
rj* LOCATION OF R---I-S---K-: ENTIRE *S-TATE' O*-%Fr rTeEvXAACS
I . /> / B DIVIDED RISK-EXPLAIN OPERATION COVERED BY THIS POLICY
i ;/ Se SJdorsement attached
fe\ vV? ^-------------------------------------------------- 1
POLICY
errecrivg date i;qt w
t_ -W---C---S----5--9-8--9-8------------------
1-5-77
-----------------------
.'^O NEW POLICY
0 RENEWAL
0 EXPIRES AT 12:01 A.M. ON..
WSURAMCKCO.
A
_j.-5r-.8Q_
*" *
' APPROXIMATE NUMBER OF EMPLOYEES:
A. Stable Annual Employment:_______ 73^----------------------------------------- -----------i--------
\t Be Seasonal Employment by Month:
JAN.
MAY JUN. JUL Auer "HE"
Oil Refining S 6; OCCUPATION
. AOORESS
" X-
, . r`. ;
. e-i. x: ;v;
' ' *sv-* h^v\ */-' - >^yr"
ajv .cit /
l r*fe
jEMHOYER SfGH Mflte .. ;
1 &>.W. I INSURANCE iXMPANY SION HERE
M Sfe^TEXASEMPLOYERS INSURANCE ASSOCIATION /_
1 ftflj^gO^yHiflAHCC COMPANY OH ASSOCtATtCK - ,,
"tstuof person rwhihg notice
UALt.-,
...
jSIGNATURE HERE CtmSTITUrES NOTICE CK BEHALF OF EMPLOYER I
i
NOTE: RETURN THIS NOTICE
-7 * JSk
- .-''. 7EXAS EMPLOYERS INSURANCEASSOtiATWH^VK r. n -
i - DO NOT.MML TO INDUSTRIAL ACCIDENT
BOARD,:--'..
-
-s m
qffSm