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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 04-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENTCALIFORNIA <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 />1/13 <br />The additional premium for this endorsement shall be _____% of the California workers’ compensation premium otherwise due <br />on such remuneration. <br />Schedule <br />Qfstpo!Ps!Pshboj{bujpoKpc!Eftdsjqujpo <br />Boz!qfstpo!ps!pshboj{bujpo!bt!sfrvjsfe!cz!xsjuufo!dpousbdu <br />xjuijo!tubuft!dpwfsfe!voefs!uijt!qpmjdz/ <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 />XD!QJ!2421259.112 <br />Endorsement Effective 1:01803136 Policy No. Endorsement No. <br />Insured Insurance Company <br />CBDLIBVT!EBODF <br />Uif!Qjf!Jotvsbodf!Dpnqboz <br />Countersigned By <br />WC 04 03 06 <br />(Ed. 04-84) <br />