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WC 04 03 06 <br />(Ed. 04-84) <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <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 enforce <br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br />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 the work <br />described in the Schedule. <br />The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise <br />due on such remuneration. <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 <br />Insured <br />Insurance Company <br />WC 04 03 06 <br />(Ed. 04-84) <br />Policy No. <br />Endorsement No. <br />Premium: <br />Countersigned by <br />} REVIEWED & APPRav D By. <br />Risk Management Specialist <br />