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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br /> (Ed. 04-84) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br /> CALIFORNIA <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce <br /> our right against the person or 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 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 2.50% of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> SCHEDULE <br /> PERSON OR ORGANIZATION JOB DESCRIPTION <br /> Any Person or Organization for which the insured has agreed by <br /> written contract executed prior to loss to furnish this waiver <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 /> Endorsement Effective 6121202512:01 AM Policy No.CS-WC-030088-02 Endorsement No. 0 <br /> Insured Southern California Precision Concrete, Inc. Premium Included <br /> Insurance Company Clear Spring Property and Casualty <br /> Company Countersigned by <br /> ©1998 by the Workers'Compensation Insurance Rating Bureau of California. All rights reserved. <br /> From the WCIRB's California Workers' Compensation Insurance Forms Manual 0 1999. <br />