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I <br /> POLICY NUMBER; 09-0037-245 <br /> WAIVER OF OUR. RIGHT i <br /> TO RECOVER FROM OTHERS ENDORSEMENT <br /> CALIFORNIA <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy.We will <br /> not enforce our right against the person or organization named In the Schedule. (This agreement applies <br /> only to the extent that you perform work under a written contract that requires you to obtain this <br /> agreement from us.) <br /> You must maintain payroll records accurately segregating the remuneration of your employees while <br /> engaged in the work described In the Schedule. <br /> 'rho additional premium for this endorsement shall be of the California workers'compensation <br /> premium otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> Specific Waiver., <br /> Blankot Waiver. <br /> Any Person Or Organization For Whom You Are Required, Human Services <br /> By Written Contract Or Agreement To Obtain This Waiver <br /> From Us <br /> This endmserrient changes the policy to wirloh It is attached and is affective on the date Issued unless offierwlse slated. <br /> (The Information boiow Is required only when this endorsement Is Issued subsequent to preparation of the policy.) <br /> Endorsement Effective Polioy No. Endorsement No. <br /> Insured Insurance Company <br /> Countersigned by _ <br /> i <br /> I <br /> WC 04 03 06 04 84 Page 1 of 1 } <br /> I <br /> i I <br /> I , <br />