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<br />/. <br /> <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> <br />WC 04 03 06 <br />(Ed. 4-84) <br /> <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA <br /> <br />We have the right to recover from 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 under a <br />written contract that requires you to obtain this agreement from us.) <br /> <br />You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the worn described in <br />the Schedule. <br /> <br />The additional premium for this endorsement shall be 0.0 % of the California workers' compensation premium otherwise due on such <br />remuneration. <br /> <br />SCHEDULE <br /> <br />Person or Organization <br /> <br />Job Description <br /> <br />Any person or organization as required by written contract <br /> <br />Blanket Waiver <br /> <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 /> <br />Endorsement Effective: <br /> <br />Policy No. WC0283135400 <br /> <br />Endorsement No.. 1 <br /> <br />Insured: Crosstown Electrical & Data, Inc. <br /> <br />Insurance Company: American Zurich Insurance Company <br /> <br />Countersigned By: <br /> <br />WCD40306 <br />(Ed, 04-84) <br />Copyright 1983 National Council on Compensation Insurance. <br />