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<br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE <br />POLICY WC 04 03 06 (Ed 4-84) <br /> <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br /> <br />ENDORSEMENT - <br /> <br />CALIFORNIA <br />This endorsement changes the policy to which it Is attached effective on the <br />inception date of the policy unless a different date is I ndicated below. <br />(The following "attaching clause" need be completed only when this endorsement Is Issued subsequent to preparation of the policy.) <br /> <br />This endorsement effective on 10/15/2008 at I 2:01 AM standard time, forms a <br />part of <br /> <br />Policy No. WC916014201 <br /> <br />Endorsement No <br /> <br />of the <br />Issued to PSOMAS <br /> <br />Zurich American Insurance Co <br /> <br />~ <br /> <br />Premium (If any) <br /> <br />Authorized Representative <br /> <br />We have the right to recover our payments from anyone liable for an Injury <br />covered by this policy. We will not enforce our right against the person or <br />organization named in the Schedule. (This agreement applies only to the extent <br />that you perform work under a written contract that requires you to obtain this <br />agreement from us) <br /> <br />You must maintain payroll records accurately segregating the remuneration of <br />your employees while engaged in the work described in the Schedule. <br /> <br />The additional premium for this endorsement shall be 5% of the California <br />workers' compensation premium otherwise due on such remuneration. <br /> <br />Schedule <br /> <br />Person or Organization <br /> <br />Job Description <br /> <br />WC 252 (4-04) <br /> <br />we 04 03 06 (Ed. 484) <br /> <br />Page 1 of 1 <br />