Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br /> This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a <br /> different date is indicated below. <br /> (The following"attached clause"need be completed only when this endorsement is issued subsequent to <br /> preparation of the policy.) <br /> This endorsement,effective on September 01,2024 at 12:01 A.M. standard time,forms a part of <br /> (DATE) <br /> Policy No. 406-04-54-43-0006 Endorsement No. <br /> of the Atlantic Specialty Insurance Company <br /> (NAME OF INSURANCE COMPANY) <br /> issued to E.J. WP tRD, INC. <br /> Premium (if any)$ <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 2.00 % of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> ALL PERSONS OR ORGANIZATIONS ON FILE WITH <br /> THE INSURED <br /> WC 252(D4 84) Copyright 1984, Intact Insurance Group USA LLC <br /> E-INSURED <br />