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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 our <br />right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform <br />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 <br />due on such remuneration. <br />Person or Organization <br />APPLIES AS BLANKET WAIVER <br />FOR THOSE HAVING A WRITTEN <br />CONTRACT WITH THE POLICY- <br />HOLDER REQUIRING WOS FOR <br />WC POLICYHOLDER EMPLOYEES. <br />% of the California workers' compensation premium otherwise <br />Schedule <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 4-1 " Policy No. WDF-D928932 Endorsement No. <br />Insured S-r t" TS on E-r-11 b 1 rS E-C- k 5 I I-,j L _ <br />Insurance Company MASSACHUSETTS BAY INSURANCE COMPANY <br />Countersigned By <br />WC 04 03 06 (Ed 04-84) <br />o Risk Managmu ad D vision <br />REVIEWED & APPROVED BY: <br />A-f, &,Vay, <br />�"'��� Risk ManagementSpeoalist <br />