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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT - CALIFORNIA <br />This endorsement changes the policy to which it is attached and is effective on the data Issued unless <br />otherwise stated. <br />This endorsement, effective on 7/1/03 at 12:01 A.M. standard time, fors a part of: <br />Policy No. WVA8004695 <br />Endorsement Notice <br />of the St. Paul Fire and Marine Insurance Company NCCI Carrier Code 13706 <br />Issued to: Vandorpe Chou Associates, Inc. Premium: <br />Policy Expiration Date: 7/1/04 <br />Authorized Representative <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 3% of the California workers' compensation premium <br />otherwise due on such remuneration. <br />SCHEDULE <br />Person or Organization <br />Anyone for whom the Named insured has agreed to furnish this waiver. <br />Minimum Premium: $100.00 <br />The premium for this coverage will be determined and billed at Audit. <br />AI'i'I20VED AS 1() CORM <br />i_Yhra Sheedy <br />{)epoty City Attorney <br />WC 04 03 08 (Ed. 04 84) Printed in U.S.A. <br />t 'd HEM 906049Z (6t6) H)MflSNI d127dwu WVS�:6 HH '0I 'M <br />