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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed.04-84) <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 you <br />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 2.00% of the California workers' compensation premium <br />otherwise due on such remuneration, <br />Schedule <br />Any Person or Organization as Required By Written Contract Any Person or Organization as Required By Written <br />Contract <br />All Operations of the Name Insured <br />This endorsement changes the policy to which It is attached and is effective on the date issued unless otherwise stated, <br />(The Information below Is required only when this endorsement Is issued subsequent to preparation of the policy.) <br />Endorsement Effective 2019-02-01 <br />Insured <br />Interval House <br />Insurance Company <br />New York Marine and General Insurance <br />Company / 28746 <br />WC 04 03 06 <br />Policy No. Endorsement No. <br />WC201900005078 <br />Countersigned <br />(Ed. 04,84) <br />01098 by the Workers' Compensation Insurance Being Bureau of California, All rights reserved. <br />�Q <br />00 � <br />0 V <br />407 81a <br />