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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />We have the right to recover from 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 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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be 0.0 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />SCHEDULE <br />Person or Organization: <br />Any person or organization that the insured is required by written contract to name as an additional insured. <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: 06/03/2011 Policy No.: WCO283135403 Endorsement No. <br />Named Insured: CROSSTOWN ELECTRICAL & DATA, INC. <br />Policy Effective Date: 06/03/2011 to 06/03/2012 <br />Insurance Company: AMERICAN ZURICH INSURANCE COMPANY <br />Countersigned By <br />WC 252 (4-84) <br />WC 04 03 06 (Ed. 4-84) <br />,`i TO FORM <br />_tit c1�J <br />