Laserfiche WebLink
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 04 03 Ota (Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -- <br />CALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a <br />different date is indicated below. <br />(The following "attaching clause" need be completed only when this endorsement Is issued subsequent to preparatlon of the pollcy.) <br />This endorsement, effective on 0e111112017at 12:01 A.M. standard time, forms a part of <br />(DATE) <br />Policy N0. WZC A399946 03 <br />of the Hanover Insurance Co <br />(NAME OF INSURANCE COMPANY) <br />Issued to BUCKNAM INFRASTRUCTURE GROUP INC <br />Premium (if any) $ <br />Endorsement No. <br />Authorized Representative <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, (This agreement applies only to the <br />extent that you perform work under a written 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 <br />the work described In the Schedule. <br />The additional premium for this endorsement shall be J % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />Blanket Per Written Contract <br />WC 252 (4.84) <br />WC 04 03 06 (Ed. 4-84) Page i of 1 <br />REVIEWED BY: EUNICE HEREDIA (PG OF <br />