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POLICY NUMBER: 5300003485181 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />"' 2—C,(5 1S3 <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 />SCHEDULE <br />ANY PERSON OR ORGANIZATION FOR <br />WHOM THE NAMED INSURED HAS AGREED <br />BY WRITTEN CONTRACT TO FURNISH <br />THIS WAIVER. <br />JOB DESCRIPTION <br />-\LVIEWED BY: <br />- 1998 by the Workers' Compenwtlon Insurance Rafing Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999. <br />INSURED COPY <br />