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Workers' Compensation and Emolovers' Llabillty Policv <br />Named Insured <br />BARRETT BUSINESS SERVICES, INC. UCIF <br />Endorsement Number <br />DEKRA -UTE INDUSTRIES, INCORPORATED <br />8100 NE PARKWAY DRIVE, STE. 200 VANCOUVER WA 98662 <br />Policy Number <br />Symbol: RWC Number: 048533085 <br />Policy Period <br />Effective Date of Endorsement <br />10-01 -2015 TO 10-01 -2016 <br />10-01 -2015 <br />Issued By (Name of Insurance Company <br />ACE AMERICAN INSURANCE COMPANY <br />Insert ft Policy number, The remainder of the Inlormafton Is to be completed when this endorsement is Issued subs vent to the preparsuen of the policy, <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <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 />1. ( ) Specific Walver <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 />Aathadwd Agent <br />WC 99 03 22 <br />