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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br />WC 04 03 06 <br />(Ed. 04.84) <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 2% of the California workers' compensation premium otherwise due on <br />such remuneration. <br />Person or Organization <br />Schedule <br />Job Description <br />Any person or organization for which you have agreed to waive your rights of recovery in a <br />written contract, provided such contract was executed prior to date of loss. <br />This endorsement changes the policy to which it is attached and is elfactive on the date issued unless otherwise stated. <br />(The InWmetbn below is rsWir9d eNy whsn this wtlor nt M issued a ft"u nt to prepsuaon of the policy.) <br />Endorsement Ellective 06/16/2014 Policy No. EQB0102132 Endorsement No. 000 <br />Insured LABELLE MARVIN INC <br />Insurance Company PRAETORIAN INSURANCE COMPANY <br />Countersigned By <br />EQB0102132 20140616 000 <br />Created by Neevia docuPrinter trial version <br />