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Hanover <br />Insurance Group.. <br />WZFD928932 5701761 <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 our <br />right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform <br />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 <br />due on such remuneration. <br />Person or Organization <br />APPLIES AS BLANKET WAIVER <br />FOR THOSE HAVING A WRITTEN <br />CONTRACT WITH THE POLICY- <br />HOLDER REQUIRING WOS FOR <br />WC POLICYHOLDER EMPLOYEES. <br />% of the California workers' compensation premium otherwise <br />Schedule <br />Job Description <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 i- Zo"�-�l Policy No. W Z F- D 9 2 8 9 3 2- 0 5 Endorsement No. <br />Insured Li cir dry Eft ��"N to l,s -11 C_ . <br />Insurance CompanyTHE HANOVER AMERICAN INSURANCE COMPLhLY <br />2iCountersigned By <br />WC 04 03 06 (Ed 04-84) <br />µorzAN Risk Management Division <br />REVIEWED & APPROVED BY. - <br />Risk Management Specialist <br />