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WORKERS CC)MPENSATION AND EkIPLQYERS I IFlLILITY INSIJFtANCE POLICY WC DA 00 06 <br />(etl. <t-E4J <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENOORSEMENT-CALIFORNIA <br />Yla hake the right to remer oto prmytnants tram anyom iiahla for an injury coy wed by this policy, Vie will rot enforce our <br />right against tho Peron or orgarvzation named in the;SChedule. (this agree-merd applies Only to tris extent that you perfrnrt <br />wil< under a wrttien crctrar.,t that reyaairzs Vou to gbtain this agreement frran us ) <br />You must malntaw payroll records accurately segregating the remur!etation of your eroplayees mdrile engaged in the oxrla <br />drscrhod to trio Scredule. <br />Tia adltional pmrnirlm for this endersorlent shall be _2 Q_'/, of the Califomis wwa om' ccmtpensation Premiiurn olherMso due <br />ct, such remuneration <br />Schedule <br />Person or Oreanlaatien Jab Description <br />Amy person or organizauar ac rRquired ty wntfen Comrar.t <br />This eneorsement ahangcs the policy la Wilton It is unsoiled and is edea.tkc on the date tssuad unless atih mwise stated. <br />(The information below Is required only whon this endorsement is issued subsequontto preparation of the policy.) <br />Endarsomont Effective Dat= tri 72017 pollry No, CS fIX00;382 Lndorzewn nl No. <br />aohey Fmrc+ilm Dales. olioll2017-01YOIi2M Premium :p <br />knsured- Foddrtli Consuuulion Corp_ <br />C;_saier Name 1 Code. Hpnchmado arsumnor. Company A <br />'Al,' Ori 13 1`18 �(l <br />;Fri 4-84'; C aur1'`,ters gnpd ,_ _ <br />_ Palle " U Y <br />REVIEWED BY: M// IJP EUNICE HEREDIA (PG ';bF% ) <br />