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<br />-, <br /> <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br /> <br />WC:!S2 <br />(4-84) <br /> <br />we 04 03 06 lEd. 4-64) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- <br /> <br />This endorsement changes the policy to which it is attached efteclive on the inception date of the policy unless a <br />different date is indicated below. . <br />(The following ~attac:hing c"usQ'~ need be completed only whQn this endorS'iment is i$sued subSlqulInt to preparation 01 the policy) <br /> <br />This endorsement, effective an <br /> <br />11/0]/05 <br />lOA"lE) <br /> <br />at 12:01 A. M. standard time, forms a part of <br /> <br />Policy No. <br /> <br />7160-35-81 <br /> <br />of the <br /> <br />FEDERAL INSURANCE COMPANY <br />(NAME OF iNSURANCE COMPANY) <br /> <br />ACE PARKING MANAGEMENT, INC. <br />(SEE NAMED INSURED ENDT.) <br /> <br />Endors6Iment No. <br /> <br />issued to <br /> <br />We have the "ghllo recover our paymen's from anyone liable for an injury covered by this policy. We will not entorce <br />our righ' against the person or organization named in the Schedule. (ThO> agreement applies only to the extent that you <br />pertarm work under a written contract that requires you to obtain this agreement trom us.) <br /> <br />Y QU must maintain payroll records accurately segregating the remuneration of your employees while engaged in the <br />work de-scribed ir. the Schedule. <br /> <br />The additional premium lor this endorsement shall be 0 c/o of the California workers' compensation premium <br />otherwise due on such remuneration. <br /> <br />Schedule <br /> <br />Person or Organization <br /> <br />Job Description <br /> <br />BLANKET WHERE REOUIRED BY <br /> <br />WRITTEN CONTRACT <br /> <br />we 252: (A~84) <br />we 04, 03 06 (Eoj, 4-84) <br /> <br />~ &/er <br /> <br />Paga 1 of 1 <br />