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. AM <br />THIS ENDORSEMEN r CHANGES THE POLICY. PLEASE READ I r CAREFt.1U.M. <br />WAIVER OF OUR RIGH"'I'TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />PoiicyNurnberr FT.3f"'t8i1 Endorsement Nurnber: <br />Effective Date-, I/ L 'o Effective hour is the sarne as stated on the Intormation Page of the policy. <br />Narmed insured and Address- AE;;C0 TNC , <br />1-;78.'2 GE0RG!2;'.L'0NQ11 LN <br />HUNTI.NGTONi 9264-11 <br />We have the right to recover- our payments from anyone liable 1br an injury covered by this policy. We will riot <br />enforce our right against the person or organization named in the Schedule. (This agreement applies only to the <br />extent that you perform Work Under a written contract that requires YOU to obtain this agr8eMeilt from US,) <br />YDU TTILJsl maintain payroll records accurately segregating the remuneration of your employees while engaged in <br />the work described in the Schedule. <br />The additional Prerr1iUrn for this endorsement shall be <br />prerniurn otherwise due on SUch remuneration. <br />Person or Organizaflon <br />ANY !'"IERSON LA!' CPG?-NIZP'j <br />'r-Ft,0M WHON YOU ARE RTQUIFELD <br />5V ('YD1\)TP1J-,,C'T OP <br />T() THIS, <br />% of the California workers' compensation <br />Job Description <br />T.. j j I 'i�j T T T F. N <br />Countersigned by,,_ <br />AUtl16i'Tz"e'cd Representative <br />Form WC 04, 03 06 (1) Printed in U.S. <br />iraticm Dale� <br />Process Date: 02 pmicy 11-r <br />REAEVVED Y x' F r E(.)MCE HERMA (r, <br />. . .... ..... <br />