Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br /> (Ed.04-84) <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 our right <br /> against the person or organization named in the Schedule.(This agreement applies only to the extent that you perform work <br /> 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 0.05 %of the California workers'compensation premium otherwise due <br /> on such remuneration. <br /> Schedule <br /> Person Or Organization Job Description <br /> CONCRETE OR CEMENT WORK—pouring or finishing <br /> of concrete sidewalks, driveways, patios,curbs or gutters <br /> —including the making or stripping of forms—employees <br /> whose regular hourly wage equals or exceeds$32.00 per <br /> City of Santa Ana hour Assignment of this classification is subject to <br /> verification at the time of final audit that the employee's <br /> regular hourly wage equals or exceeds$32.00 per hour. <br /> The payroll of an employee whose regular hourly wage is <br /> not shown to equal or exceed$32.00 per hour shall be <br /> classified as 5201(1), Concrete or Cement Work. <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 12/01/2024 Policy No. WC PI 1381000-000 Endorsement No. 002 <br /> Insured Jarrar, Ahmad Insurance company The Pie Insurance Company <br /> Countersigned By 9 C <br /> WC 04 03 06 <br /> (Ed.04-84) <br /> APPROVED 1' <br />