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<br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />CA10000979111 12/30/2011 <br />TSCM Corp <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 that <br />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 2 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />SCHEDULE <br />PERSON OR ORGANIZATION <br />JOB DESCRIPTION <br />ANY PERSON OR ORGANIZATION FOR WHOM ALL OPERATIONS <br />THE NAMED INSURED HAS AGREED BY <br />WRITTEN CONTRACT TO FURNISH THIS <br />WAIVER. <br />T4 yo-*A <br />AppR?V?D AS <br />?STORCK <br />LISA E• Attorney <br />Assistant City <br />. 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's Califomia Workers' Compensation Insurance Forms Manual - 1999. <br />