Laserfiche WebLink
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 <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 0.02 %of the California workers'compensation premium otherwise due <br /> on such remuneration. <br /> Schedule <br /> Person Or Organization Job Description <br /> Any person or organization as required by written contract <br /> within states covered under this policy. <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 01/24/2024 Policy No. WC PI 710827-000 Endorsement No. <br /> Insured Embee Computer Design Inc Insurance Company The Pie Insurance Company <br /> Countersigned By <br /> o„Pat, Risk Management Division <br /> 3, REVIEWED&APPROVED BY: <br /> 'irID1-------,d1' AaNzit, <br /> rommst <br /> WC 04 03 06 �-� Risk Management Specialist <br /> (Ed.04-84) / <br />