Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICYWC 04 03 06 <br />(Ed. 4-84) <br /> <br />WAIVEROF OUR RIGHTTORECOVER FROMOTHERS ENDORSEMENTCALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforceWe have the right to recover our payments from anyone liable for <br /> 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 thatour right against the person or organization named in the Schedule. <br /> (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.)you perform work under a written contract that requires you to obtain this agreement from <br /> 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 />2 <br />The additional premium for this endorsement shall be _____% of the California workersÓ compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or OrganizationJob Description <br />Djuz!pg!Tboub!Bob- <br />Jobs performed for any person or organization that you <br />jut!pggjdfst-!pggjdjbmt!boe!fnqmpzfft <br />have agreed with in a written contract to provide this <br />agreement. <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 EffectivePolicy No.Endorsement No. <br />220203136QTX11155:4 <br />InsuredInsurance Company <br />RLI Insurance Company <br />Y!Fohjoffsjoh!'!Dpotvmujoh <br />Countersigned By <br />¨1998 by the WorkersÓ Compensation Insurance Rating Bureau of California. All rights reserved. <br />9:569835!}!22036.37!HM-!BVUP-!FYDFTT-!XD!'!QM!!}!)BWD*!Cfuuz!Usbo!}!303703137!4;13;66!QN!)QTU*!}!Qbhf!31!pg!32 <br /> <br />