Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed. 4-84) <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 not enforce <br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that <br />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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be 2% of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Person or Organization <br />Schedule <br />Job Description <br />All persons or organizations that are party to a contract that Jobs performed for any person or organization that you <br />requires you to obtain this agreement, provided you executed have agreed with in a written contract to provide this <br />the contract before the loss. agreement. <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 05/0e12021 Policy No. PSW0005179 Endorsement No. <br />Insured John Robinson Insurance Company <br />RLI Insurance Company <br />Countersigned By <br />©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />Risk Visism <br />REmEwED ® APPRov <br />Fo� P1, V:LG'nal <br />® Ru k Management Analyst <br />