Laserfiche WebLink
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />Policy Number: 45 WEC AV7H87 Endorsement Number: <br />Effective Date: 01/27/24 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: The Jay Particle, LLC <br />3501 W MOORE AVE STE J <br />SANTA ANA CA 92704 <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our <br />right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br />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 work <br />described in the Schedule. <br />The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due <br />on such remuneration. <br />SCHEDULE <br />Person or Organization <br />Job Description <br />Any person or organization for whom you are required by written contract or agreement to obtain this waiver of rights from <br />us <br />Countersigned by <br />Form WC 04 03 06 (1) Printed in U.S.A. <br />Process Date: 12/18/23 <br />t„sn1�1 <br />RiskMuaganoiDmown <br />REVIEWED a Appmfso Br: <br />A.jU"4 <br />RA Management Specialist <br />01 <br />Policy Expiration Date: 01/27/25 <br />