Laserfiche WebLink
Workers' Compensation and Emolovers' Liability Policv <br />B 11 <br />SARR RRET7 B Z USINESS SERVICES, INC. L/C/F <br />Endorsement Number <br />DEKRA -CITE INDUSTRIES, INCORPORATED <br />Policy Number <br />8100 NE PARKWAY DRIVE, STE. 200 VANCOUVER WA 98682 <br />Symbol: RWC Number. 048099270 <br />Popsy Period <br />Effective Date of Endorsement <br />10- 26.2014 TO 10-01-2016 <br />10.26.2014 <br />Issued By (Name of Insurance Company) <br />ACE AMERICAN INSURANCE COMPANY <br />Insert Me Policy number. The remainder of the Information Is to be COMPlet0d Qn1V when this endorsement Is Issued subsequent to the preparation al the <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <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 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 />Schedule <br />I. ( ) 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 />3. Premium: <br />The premium charge for this endorsement shall be 2.0 percent of the California premium 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: $0 <br />Aulha d Agent <br />F02 <br />