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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 89 06 00 B <br />POLICY INFORMATION PAGE ENDORSEMENT <br />The following item(s) <br />❑ Insured's Name (WC 89 06 01) <br />❑ Policy Number (WC 89 06 02) <br />❑ Effective Date (WC 89 06 03) <br />❑ Expiration Date (WC 89 06 04) <br />❑ Insured's Mailing Address (WC 89 06 05) <br />❑ Experience Modification (WC 89 04 06) <br />❑ Producer's Name (WC 89 06 07) <br />❑ Change in Workplace of Insured (WC 89 06 08) <br />❑ Insured's Legal Status (WC 89 06 10) <br />❑ Item 3.A. States (WC 89 06 11) <br />is changed to read: <br />It is understood and agreed that: <br />❑ Item 3.13. Limits (WC 89 06 12) <br />❑ Item 3.C. States (WC 89 06 13) <br />(Ed. 7-01) <br />X7 Item 3.D. Endorsement Numbers (WC 89 06 14) <br />❑ Item 4.* Class, Rate, Other (WC 89 04 15) <br />❑ Interim Adjustment of Premium (WC 89 04 16) <br />❑ Carrier Servicing Office (WC 89 06 17) <br />❑ Interstate/Intrastate Risk ID Number (WC 89 06 18) <br />❑ Carrier Number (WC 89 06 19) <br />❑ Issuing Agency/Producer Office Address (WC 89 06 25) <br />The following forms are added: <br />WC 00 03 13 - Waiver Of Our Right To Recover From Others Endorsement <br />All other terms and conditions remain unchanged. <br />*Item 3.D. Change to <br />Form Number <br />WC 89 06 00 B (07-01) <br />WC 04 03 06 <br />WC 89 06 00B <br />(Ed. 7-01) <br />Form Title <br />Policy Information Page Endorsement <br />Waiver of Our Right to Recover from Others Endorsement -- California <br />O 2001 National Council on Compensation Insurance, Inc. <br />