Laserfiche WebLink
Worker's Compensation and Employer's Liability Insurance Policy <br />Waiver of Our Rights to Recover From Others Endorsement — CA <br />WC 04 03 06 <br />If the following information is not complete, refer to the appropriate Schedule attached to the policy. <br />Insured: Advanced Critical Care 8c Inter Policy Number: WZP80984421 <br />Producer: Veterinary Ins Services Co Eff Date: 07 /OL /10 to 07/01/1 1 <br />�ceeaule <br />Person or Organization <br />City of Santa Ana <br />Additionai Premium <br />We have the right to recover our payments from any- <br />one liable for an injury covered by this policy. We will <br />not enforce our right against the person or organization <br />named in the Schedule. (This agreement applies only <br />to the extent that you perform work under a written <br />contract that requires you to obtain this agreement <br />from us.) <br />Job Description <br />You must maintain payroll records accurately segre- <br />gating the remuneration of your employees while en- <br />gaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be <br />the percentage, as shown in the Schedule applicable <br />to this endorsement, of the California worker's com- <br />pensation premium otherwise due on such <br />remuneration. <br />This form must be attached Co Change Endorsement when issued after the policy is written. <br />One of the Fireman's Rund Insurance Companies as named in the policy. <br />SaFlry �. rXary <br />secretary <br />/�� Cruz <br />Authorized Agent <br />WCO40306 9-80 <br />91[icliaeC�. Ga4eocco <br />President <br />lorzs /lo <br />