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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />CA10000979121 1/3/2013 <br />TSCM Corporation <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 />Ns TO F0t% <br />T'S9Y?QV? r Y\ <br />;io <br />Ity (at <br />Assistant ? <br />-'1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. 5 <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. I <br />