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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br />enforce our right against the person or organization named in the Schedule. (This agreement applies only to the <br />extent that 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 <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be <br />compensation premium otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />2 % of the California workers' <br />Job Description <br />ANY PERSON OR ORGANIZATION REQUIRED BY WRITTEN CONTRACT OR CERTIFICATE OF INSURANCE <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 Policy No. Endorsement No. <br />Insured Premium $ <br />Rick Management DMsirnt <br />REVIEWED & APPROVED BY. <br />Insurance Company Countersigned by l <br />® Risk Management Specialist <br />WC 04 03 06 <br />(Ed. 4-84) Copyright 1999 National Council on Compensation Insurance, Inc. Reorder No. 14-2420 <br />