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POLICY NUMBER: 5300003485181 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce <br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that <br />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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be <br />otherwise due on such remuneration. <br />PERSON OR ORGANIZATION <br />% of the California workers' compensation premium <br />6Yfl:1:111154 <br />ANY PERSON OR ORGANIZATION FOR <br />WHOM THE NAMED INSURED HAS AGREED <br />BY WRITTEN CONTRACT TO FURNISH <br />THIS WAIVER. <br />AA71r7�3a 713YN7� <br />-1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. <br />INSURED COPY <br />-7 �'""' �/ V Z fJ�4�� 21 u f <br />