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F1 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />Policy Number: 72 WEC GF7491 Endorsement Number: 02 <br />Effective Date: 10/09/14 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: TRIPEPI SMITH & ASSOCIATES <br />PO BOX 52152 <br />IRVINE, CA 92619 <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 <br />premium otherwise due on such remuneration. <br />Person or Organization <br />ANY PERSON OR ORGANIZATION <br />FROM WHOM YOU ARE REQUIRED BY <br />WRITTEN CONTRACT OR AGREEMENT <br />TO OBTAIN THIS WAIVER OF <br />RIGHTS FROM US <br />SCHEDULE <br />% of the California workers' compensation <br />Job Description <br />BLANKET OPERATIONS <br />Countersigned by <br />Authorized Representative <br />Form WC 04 03 06 (1) Printed in U.S.A. <br />Process Date: 10/09/14 Policy Expiration Date: 06/20/15 <br />