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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 2 %e of the California workers' compensation premium <br />otherwise due on such remuneration. <br />SCHEDULE <br />PERSON OR ORGANIZATION <br />JOB DESCRIPTION <br />ANY PERSON OR ORGANIZATION FOR BLANKET WAIVER OF SUBROGATION <br />WHOM THE NAMED INSURED HAS AGREED <br />BY WRITTEN CONTRACT TO FURNISH <br />THIS WAIVER <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 Effective05-22-19 Policy No.7600020438191 Endorsement No. 001 <br />Insured VIDO SAMARZICH INC Premium $ INCL. <br />Insurance Company EVEREST PREMIER INSURANCE COMPANY <br />Countersigned By, <br />1999.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 />NWREO COPY <br />