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Workers' Compensation and Employers' Liability Insurance Policy <br />Waiver of Our Right to Recover From Others Endorsement - California <br />WC 04 03 06 <br />If the following information is not complete, refer to tate appropriate Schedule attached to the policy, <br />Insured: Dudek <br />Producer: Michael J. Ball & Company <br />Schedule <br />Person or Organization <br />.Any Person or Organization for which the insured <br />has agreed by written contract executed prion to loss <br />to ftunish this waiver <br />Additional Preutfum % <br />We have the right to recover our Payments from <br />anyone liable for an injury covered by this policy. <br />We will not enforce our right against the person or <br />organization named in the Schedule. (This agr'eentent <br />applies only to the extent dont you perform work <br />under a written contract that requires you to obtain <br />this agreement from us.) <br />Policy Number: WC81030014 <br />Effective Date: August 28, 2015 <br />Job Description <br />You must maintain payroll records accurately <br />segregating the rermutteration of yotu employees <br />while engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall he <br />the percentage, as shown in the Schedule applicable <br />to this endorsement, of the California workers' <br />compensation premium otherwise due on such <br />.remuneration. <br />This Fomr must be attached to Change Hndorsenunr Mica issued anee the policy is written. <br />One of the rlrennn's Fund Insurance Campsites as named in the policy <br />Si:Liti• 'yam l,, a! I� <br />W0040308 4.84 <br />REVIEWED BY: Et1N ( NEREDIA IPG �J' <br />