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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <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 our right against <br />the person or organization named in the Schedule, (This agreement applies only to the extent that you perform work under a written <br />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 work described in <br />the Schedule. <br />The additional premium for this endorsement shall be % of the California workers' compensation premium otherwise due on <br />such remuneration. <br />SCHEDULE <br />PERSON OR ORGANIZATION JOB DESCRIPTION <br />As required by written contract executed prior to a Loss. <br />This endorsement changes the policy to which it is attached and is effective on the data Issued unless otherwise stated, <br />(The information below is required only when this endorsement Is Issued subsoquentto preparation orthe policy.) <br />Endorsement Effective: 12 %01/13 PolicyNo.; WCA2007167 -11 Endorsement No, I <br />InsuredC H P Enterprises, Inc, Premium <br />Insurance Company Great Divide Insurance Company <br />Countersigned S 1 0, X.AA� (bA X <br />J <br />01998 by the Workers' Compensation insurance Rat(ng Bureau of California, All rights reserved, <br />From the WCTRS's Califomin Workers' Compensation Insurance Forms Manuel t91999 <br />