Laserfiche WebLink
WORKERS'. COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE <br />POLICY WC 04 03 06 (Ed 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT - <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 Indicated below. <br />(The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) <br />This endorsement effective on 10115/10 at 12:01 AM standard time, forms a part of <br />Policy No. WC916014203 <br />of the <br />Issued to. Psomas <br />Premium (If any) <br />Endorsement No <br />Zurich American Insurance Co <br />k0l <br />u q <br />Authorized Representative <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 />You must maintain payroll records accurately segregating the remuneration of <br />your employees while engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be 5% of the California <br />workers' compensation premium otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />Job Description <br />SCHEDULED PERSON OR ORGANIZATION WHERE REQUIRED BY WRITTEN CONTRACT <br />WC 252 (4-04) WC 04 03 06 (Ed. 484) <br />A.3'1'_d �'' <br />Page 1 of I <br />