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POLICY NUMBER: BNUWC0154220 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 04-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA (Blanket) <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right <br />against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work <br />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 the work <br />described in the Schedule. <br />The additional premium for this endorsement shall be 0.020000 % of the California workers' compensation premium otherwise <br />due on such remuneration. <br />State <br />Schedule <br />Description <br />CA Any party with whom the insured agrees to waive subrogation in a written contract. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective Date: Policy Number: BNUWC0154220 Endorsement No.: <br />Insured Name: Insurance Company: StarNet Insurance Company <br />Countersigned By <br />oRaN <br />RiskMaaganentDMsian <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />