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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 89 06 00 B <br />(Ed. 7-01) <br />POLICY INFORMATION PAGE ENDORSEMENT <br />The following item(s) <br />F1 Insured's Name (WC 89 06 01) <br />F1 Policy Number (WC 89 06 02) <br />F1 Effective Date (WC 89 06 03) <br />u Expiration Date (WC 89 06 04) <br />u Insured's Mailing Address (WC 89 06 05) <br />u Experience Modification (WC 89 04 06) <br />u Producer's Name (WC 89 06 07) <br />u Change in Workplace of Insured (WC 89 06 08) <br />u Insured's Legal Status (WC 89 06 10) <br />u Item 3.A. States (WC 89 06 11) <br />is changed to read: <br />It is understood and agreed that: <br />— Item 33. Limits (WC 89 06 12) <br />— Item 3.C. States (WC 89 06 13) <br />X- Item 3.D. Endorsement Numbers (WC 89 06 14) <br />Item 4.* Class, Rate, Other (WC 89 04 15) <br />Interim Adjustment of Premium (WC 89 04 16) <br />Carrier Servicing Office (WC 89 06 17) <br />Interstate/Intrastate Risk ID Number (WC 89 06 18) <br />Carrier Number (WC 89 06 19) <br />Issuing Agency/Producer Office Address (WC 89 06 25) <br />The following forms are added: <br />WC 00 03 13 - Waiver Of Our Right To Recover From Others Endorsement <br />All other terms and conditions remain unchanged. <br />*Item 3.D. Change to <br />Form Number <br />WC 89 06 00 B (07-01) <br />WC 04 03 06 <br />WC 89 06 OOB <br />(Ed. 7-01) <br />Form Title <br />Policy Information Page Endorsement <br />Waiver of Our Right to Recover from Others Endorsement -- California <br />© 2001 National Council on Compensation Insurance, Inc. <br />