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07/01/21 <br />Authorized Representative <br />Policy Expiration Date: <br />Job Description <br />Endorsement Number: <br />SCHEDULE <br />Countersigned by <br />Effective hour is the same as stated on the Information Page of the policy.MANAGED CAREER SOLUTIONS, SPC3333 WILSHIRE BLVD STE 405LOS ANGELESCA90010 <br />(1) Printed in U.S.A. <br />72WECAD0S03 <br />07/01/20 <br />06/03/20 <br />Policy Number:Effective Date:Named Insured and Address:Wehavetherighttorecoverourpaymentsfromanyoneliableforaninjurycoveredbythispolicy.Wewillnotenforceourrightagainstthepersonororganizationnamedinth <br />eSchedule.(Thisagreementappliesonlytotheextentthatyouperform work under a written contract that requires you to obtain this agreement from us.)Youmustmaintainpayrollrecordsaccuratelysegregatingtherem <br />unerationofyouremployeeswhileengagedintheworkdescribed in the Schedule.Theadditionalpremiumforthisendorsementshallbe2%oftheCaliforniaworkers'compensationpremiumotherwisedueon such remuneration.Person <br /> or OrganizationAny person or organization from whom you are required by written contract or agreement to obtain this waiver of rightsfrom usForm WC 04 03 06Process Date: <br />