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<br /> NOTICE THAT EMPLOYER HAS BECOME SELF INSURER <br /> TEXAS WORKERS' COMPENSATION ACT <br /> ARTICLE 8309h, RCS <br /> Original to Industrial Accident Board. 200 E. Riverside Drive, First Floor. Austin. Texas 78704 <br /> I,mlca IS MI'1IDy gIVen Dy tntl I13I1'M1O amplOytlf as reQUIred by Article B309h. RCS.mClUåing any amendments tnereto. tNit tn. named emoloyer has beœlM <br /> iI s~1f Insurer under So1Iid arllCI~ludm!il any amenQments thereto. .no proviaeo tor the Ø8yment of compensatIon to emøioYMS unGer tna terms and <br /> OrOYISIOns thereot. Any e:noloyer tailing to fill this notIce shall be liable lor ana snail pay to the State of '8.. . p-nv 01 not more trlan F¡". huncred <br /> Dollars (5500.00) tor 8ac:"'l ottens.. <br /> EMPLOYER: C\\:y of SQ..() m~tf~.c.O 5 <br /> .DDRESS: (030 £,. \+oP~YìS stree.. t So.n t'ntÃrcoS I To)( 7 8 6.Þ.6 <br /> I <br /> SELF INSURED UNDER: T té:..X6-.s M'^t\\(~\ Pf\L L Ef\G-v..e.. Worke."~ e.ot\\~ft'r'Ø^ :ro,'",+ ~S\\r(U\( <br /> A SUBSCRIBER SHALL NOTIf-"Y THE BOARD OF A CHANGE OF NAME OR ADDRESS. F"-N I) <br /> CONTRACT OR CERTIFICATE NUMBER EFFECTIVE DATE 12:01 A.M. <br /> Ao'ì~S- 3/ \ 5\0<)' <br /> ~ , <br /> ¡ IMMEDIATE PRIOR COVERAGE WAS THROUGH: ///11 e tel C¡t:¡!l Gem eAAt- <br /> ¡ c,l.RRIER HAME <br /> I POLICY NUMBER: c,Æ /3 (lOB? 8 FROM: 3-1- Be¡ TO: '3-1 - 8r <br /> ; INOT REQUIRED I' RENEWED WITH SAME SERVICING CONTRACTO", <br /> .'.... --..------..---- .. . T or . ..- ..... .II . L . "- ..... ~:. <br /> ! f <br /> f <br /> t <br /> I :MPLOY:R~k* ' <br /> SIGNED: ~ i <br /> t71?/!IJce IIJm,nlstr~:1o1! <br /> TITLE OF PERSON SIGNING NOTICE <br /> DATE: L/~3-8S <br /> SIGNATURE HERE CONSTITUTES NOTICE ON BEHALF OF EMPLOYER <br /> , i <br /> ... -... , ..... - -- - "-"" .. "' '"- .. .. J .. 1 -"- ... ... ..... . :. <br /> I A.8 ~onn'53 fR... !Io83) <br /> A.orCle' .'-2. H8" CO'aOhtQl <br />