Laserfiche WebLink
Workers' Compensation and Employers' Liability Policy <br />Named InsuredEndorsement Number <br />HCI SYSTEMS, INC. <br />1354 S PARKSIDE PL <br />Policy Number <br />ONTARIOCA 917614555 <br />Symbol:WCF Number:54309498 <br />Policy Period <br />Effective Date of Endorsement <br />03-02-202 <br />03-02-202 TO 03-02-202 <br />Issued By (Name of Insurance Company) <br />FEDERAL INSURANCE <br />Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />ThisendorsementappliesonlytotheinsuranceprovidedbythepolicybecauseCaliforniaisshowninItem3.A.of <br />the Information Page. <br />Wehavetherighttorecoverourpaymentsfromanyoneliableforaninjurycoveredbythispolicy.Wewillnot <br />enforceourrightagainstthepersonororganizationnamedintheSchedule,butthiswaiverappliesonlywithrespect <br />tobodilyinjuryarisingoutoftheoperationsdescribedintheSchedule,whereyouarerequiredbyawrittencontract <br />to obtain this waiver from us. <br />Youmustmaintainpayrollrecordsaccuratelysegregatingtheremunerationofyouremployeeswhileengagedinthe <br />work described in the Schedule. <br />Schedule <br />1.()Specific Waiver <br />Name of person or organization: <br />X <br />WHERE REQUIRED BY WRITTEN CONTRACT. <br />()Blanket Waiver <br />AnypersonororganizationforwhomtheNamedInsuredhasagreedbywrittencontracttofurnishthis <br />waiver. <br />2.Operations: <br />3.Premium: <br />1.0 <br />The premium charge for this endorsement shall bepercent of the California premium developed <br />on payroll in connection with work performed for the above person(s) or organization(s) arising out of the <br />operations described. <br />4.Minimum Premium:$0 <br />Authorized Representative <br />WC 90 03 75 (05/18) <br />