<xdwc:BulkDWC020SI xmlns:xdwc="http://tdi.texas.gov/DWCForms" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://tdi.texas.gov/DWCForms EmployerFormsSchema.xsd">

<formData >
    <Name>Village Fire Dept</Name>
    <EffectiveDates>
        <StartDate>2024-02-10</StartDate>
        <EndDate>2025-02-10</EndDate>
    </EffectiveDates>
    <Address>
        <Line1>901 Corbindale Road</Line1>
        <Line2/>
        <City>Houston</City>
        <State>TX</State>
        <Zip>77024</Zip>
    </Address>
    <FEIN>741168025</FEIN>
    <POC>
        <Name>Morris Emily</Name>
        <Phone>
            <AreaCode>713</AreaCode>
            <Number>4687941</Number>
            <Extension/>
        </Phone>
        <EMail>morris@villagefire.com</EMail>
    </POC>
    <PoolGroupFlag>Y</PoolGroupFlag>
    <PoolGroup>
        <Name>Deep East Texas Self Isurance Fund</Name>
        <FEIN>741792014</FEIN>
        <POC>
            <Name>Dustin Hill</Name>
            <Phone>
                <AreaCode>972</AreaCode>
                <Number>3845444</Number>
                <Extension/>
            </Phone>
            <EMail>dhill@aldetsif.com</EMail>
        </POC>
    </PoolGroup>
</formData>
</xdwc:BulkDWC020SI>