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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC O4 0306 <br />(Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA <br />We, have the right to recover our payments from anyone liable for an injury covered by thls policy. We will riot 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 Job Description <br />- For proposal Purposes - Note! Non- Jobs performed for any person or organization that you <br />specific terms such as agents, volunteers, have agreed with in a written contract to provide this <br />subsidiaries, representatives, successors and agreement. <br />This endorsement changes the policy to winch it Is attached and is offeeave on the date issued unless othervriso stated. <br />iThe Information below is required only when this endorsement is Issued subsequent to preparation of the policy.) <br />Endorsement Effective 1 0131/2 01 3 policy NoPSW0001252 <br />Insured Insurance Company <br />Joseph C. Truxaw and Associates, Inc. RLI Insurance Company <br />Countersigned By <br />Endorsement No. <br />AL 7 <br />%rten <br />@1999 by the Wore ors' Cornpetisatlon Insurance Rating Bureau of California, All rights msarved. <br />�i.i, tl ���� .� lei lJtl 11 -M1ti_�l Nry Y ]i ivt 5 <br />