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WORKERSCOMPENSATIONANDEMPLOYERSLIABILITYINSURANCEPOLICYWC040306 <br />(Ed.4-84) <br />WAIVEROFOURRIGHTTORECOVERFROMOTHERSENDORSEMENTCALIFORNIA <br />Wehavetherighttorecoverourpaymentsfromanyoneliableforaninjurycoveredbythispolicy.Wewillnotenforceour <br />rightagainstthepersonororganizationnamedintheSchedule.(Thisagreementappliesonlytotheextentthatyouper- <br />form work under a written contract that requires you to obtain this agreement from us.) <br />Youmustmaintainpayrollrecordsaccuratelysegregatingtheremunerationofyouremployeeswhileengagedinthe <br />work described in the Schedule. <br />The additional premium for this endorsement shall be ____________ % of the California workers' compensation premium 1/131 <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />Cmbolfu!Xbjwfs!pg!Tvcsphbujpo!bt!sfrvjsfe!cz!xsjuufo <br />Job Description <br />dpousbdu <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(Theinformation below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />TBUJT1599811 <br />Endorsement Effective Date:Policy No.Endorsement No. <br />1401203133 <br />Premium $ <br />1401203133 to 1401203134 <br />Policy Effective Date: <br />Ljohepn!Dbvtft-!Jod <br />Insured: <br />Djuz!Ofu <br />DBA: <br />Carrier Name / Code: <br />Tfswjdf!Bnfsjdbo!Joefnojuz!Dpnqboz <br />Countersigned by <br />WC 04 03 06 <br />(Ed. 4-84) <br />11 <br />Pageof <br /> <br />