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THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. <br />Policy Number: 57 WEC EU6620 Endorsement Number: <br />Effective Date: Effective hour is the some as stated on the Information Page of the policy, <br />Named Insured and Address: CITYGATS ASSOCIATES,, LLC <br />600 COOLIDGH' DR 9TR 150 <br />F03'som ('A <br />We have the right to recover our payments from anyone Ilable 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 wrloon contract that requires you to obtain [hie, 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 prornlurn for this endorsement suall be 2 <br />otherwise duo on such ramonoratlon , <br />Person or Organization <br />Form WC 04 03 <br />Process Date: 0 6 / 2 8 / 15) <br />% of the California workers' compensation premium <br />Job Vasorliatlon <br />Countersigned by 6& ;, <br />Authodzed -Representative <br />USA <br />Policy Expiration Data: io/oVig <br />