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Workers' CornDensation and Emlolovers'Liabilitv Policy <br />Named Insured <br />Endorsement Number <br />BARRETT BUSINESS SERVICES, INC. L/C/F <br />AMERICAN WRECKING INC, <br />Policy Number <br />8100 NE PARKWAY DRIVE, STE. 200 VANCOUVER WA 98662 <br />Symbol: RWC Number: C4853692A <br />Policy Period <br />Effective Date of Endorsement <br />10-01-2015 T0, 10-01-2016 <br />10-01-2015 <br />Issued By (Name of Insurance Company) <br />ACE AMERICAN INSURANCE COMPANY <br />Insert the polio y number. The remainder of the information is to be completed only when this endorsement is Issued subsequent to the preparation of the poficy. <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of <br />the Information Page. <br />We have the right to recover 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, but this waiver applies only with respect <br />to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract <br />to obtain this waiver from LIS. <br />You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the <br />work described in the Schedule. <br />Schedule <br />1. Specific Waiver <br />Name of person or organization: <br />X ) Blanket Waiver <br />Any person or organization for whom, the Named Insured has agreed by written contract to furnish this <br />waiver, <br />2. Operations: <br />ALL CALIFORNIA OPERATIONS <br />MUM171 "111 <br />The premium charge for this endorsement shall be 2.0 percent of the California prernium developed <br />on payroll in connection with work performed for the above person(s) or organization(s) arising out of the <br />operations described. <br />4. Minimum Premium: <br />AUthorized Agent <br />-------- . ..... <br />WC 99 03 22 <br />BY� EUNICE I-iEI?E1--.)IA (PG1b)F /A <br />