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POLICY NUMBER: BNUWC0164042 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br /> (Ed.04-84) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA(Blanket) <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right <br /> against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work <br /> 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 work <br /> described in the Schedule. <br /> The additional premium for this endorsement shall be 0.020000 %of the California workers' compensation premium otherwise <br /> due on such remuneration. <br /> Schedule <br /> State Description <br /> CA Any party with whom the insured agrees to waive subrogation in a written contract. <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 Effective Date: Policy Number: BNUWC0164042 Endorsement No.: <br /> Insured Name: Sunny Hills Associates Incorporated Insurance Company: Midwest Employers Casualty <br /> Company <br /> Countersigned By <br />