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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 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 2 % of the California workers' <br /> compensation premium otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization 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 />