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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 03 13 C <br />(Ed. 7-09) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will <br />not enforce our right against the person or organization named in the Schedule. (This agreement applies <br />only to the extent that you perform work under a written contract that requires you to obtain this <br />agreement from us.) <br />You must maintain payroll records accurately segregating the remuneration of your employees while <br />engaged in the work described in the Schedule. <br />The additional premium for this, endorsement shall be $ 500 <br />Schedule <br />Any person or organization that you perform work for that is liable for an injury, covered by this policy, that <br />prior to the injury has written contract requiring a waiver of our right to recover from them. <br />Person or Organization <br />Job Description <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 07/01/2021 Polley No.WCV 5505162 Endorsement No. 000 <br />Insured FAMILIES FORWARD, INC. <br />Insurance Company COMPWEST INSURANCE COMPANY Countersigned by <br />WC990313C <br />(Ed. 7-09) <br />s �v <br />��°. <br />ltluk iMnnaganenEDlvleloa <br />REVIEWEDS�APPROVED BY: <br />I�i <br />Ruk ManagementAnrlysk <br />