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Policy Number: WCO'14633001 <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 f <br />CAUFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br />enforce our right against the person or organization named in the Schedule. (This agreement applies only to the <br />extent that you perform work under a written contract that requires you to obtain this agreement from us.) <br />You must maintain payroll records accurately segregating the remuneration of your employees while engaged in <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be ® % of the California workers' compensation pre- <br />mium otherwise due an such remuneration. <br />Person or Organization Job Description <br />ALL PERSONS AND/OR ORGANIZATIONS THAT <br />ARE REQUIRED BY WRITTEN CONTRACT OR <br />AGREEMST WITH THE INSURED, EXECUTED <br />PRIOR TO THE ACCIDENT OR LOSS, THAT <br />WAIVER OF SUBROGATION BE PROVIDED <br />UNDER THIS POLICY FOR WORMS PERFORMED <br />BY YOU FOR THAT PERSON AND/OR <br />ORGANIZATION <br />G`�l� <br />..�sG�P�pd <br />avc asz .tias� <br />