Laserfiche WebLink
WORKERSCOMPENSATIONANDEMPLOYERSLIABILITYINSURANCEPOLICYWC040306 <br />(Ed.4-84) <br />WAIVEROFOURRIGHTTORECOVERFROMOTHERSENDORSEMENTCALIFORNIA <br />Wehavetherighttorecoverourpaymentsfromanyoneliableforaninjurycoveredbythispolicy.Wewillnotenforceour <br />rightagainstthepersonororganizationnamedintheSchedule.(Thisagreementappliesonlytotheextentthatyouper- <br />form work under a written contract that requires you to obtain this agreement from us.) <br />Youmustmaintainpayrollrecordsaccuratelysegregatingtheremunerationofyouremployeeswhileengagedinthe <br />work described in the Schedule. <br />The additional premium for this endorsement shall be ____________ % of the California workers' compensation premium Tff!Cfmpx <br />otherwise due on such remuneration. <br />Schedule <br />Person orOrganization <br />Djuz!pg!Tboub!Bob-!jut!Djuz!Dpvodjm-!pggjdfst-!pggjdjbmt-!fnqmpzfft- <br />bhfout-!boe!wpmvouffst <br />JobDescription <br />Buufoujpo;!Dpnnvojuz!Efwfmpqnfou!Bhfodz-!Ipnfmftt!31!Djwjd!Dfoufs!Qmb{b- <br />N36-!Tboub!Bob!DB!:3813 <br />Tqfdjgjd!Xbjwfs!jt!%311!Gmbu!Dibshf <br />This endorsementchanges the policy towhich itis attached and is effectiveonthe dateissuedunlessotherwise stated. <br />(Theinformation below is required only when thisendorsementisissuedsubsequent topreparation of the policy.) <br />TBUJT1455:16 <br />Endorsement Effective Date:PolicyNo.Endorsement No. <br />2101203136 <br />Premium $ <br />21012031362101203137 to <br />Policy Effective Date: <br />Uipnbt!Ipvtf!Ufnqpsbsz!Tifmufs <br />Insured: <br />DBA: <br />CarrierName/Code: <br />Tfswjdf!Bnfsjdbo!Joefnojuz!Dpnqboz <br />Countersignedby <br />WC 04 03 06 <br />(Ed. 4-84) <br />11 <br />Pageof <br /> <br />