Laserfiche WebLink
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 04 03 06 (Ed. 4-SA) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALlFORNIA <br />This endorsement changes the poFCy to which it is attached affeeVva on fha Inception dat9 of Via policy unless a <br />dif/erent date b Indicated below. <br />Crnr. brow4g -aexr,a.a seas.- Haas a ewr�eerwa any wnsn ante a tamuma au�grNnt a Pres»� a ell posry. i <br />This endorsement, effective on 4/]!2D]2 at ]2:01 A.M. standard lime, Corms a part of <br />(DATE) <br />Policy No• 72 WE DQ2237 of fire HARTFORD CASUAL'T'Y INSURANCE COMPANY <br />(NAME OF INSURANCE OOMPANY) <br />issued io BEST, BEST 8 KRIEGER LLP <br />Endorsement No. <br />We have the right m recover our payments from anyone liable for an injury covered by tf� policy. We wip not anfor� <br />our right against the penwn or organization Hamad in the Schedule. (This agreement applies ony to the extent that <br />you perform work urWer a written contract that requires you to obtain this agreement from us.) <br />You must maintain payroll rsoords accuratey segregating Vie remuneration of your employees whiff engaged in the <br />work described In the Schedule. <br />TM additional premium for this endorsemenrt shall ba 1.00 % of Via California workers' oompansatton premium <br />otherwise due on such remuneration. <br />Schedule <br />_ Person or lrgantzation Job Description <br />9�TU] Santa Ana 20 Civic Caller Plaza, Santa Ana. CA See Attached Certificate and Description of Operatlons <br />WG 252 (4-84) <br />WC 04 03 08 (ED. 4-84) Page ] d i <br />wa�r.e.ne ees.- oNpn <br />deanes+. � �r�srs�+ <br />