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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE WC 04 03 06 <br /> POLICY POLICY NUMBER: ZAWC19792801 (Ed. 0484) <br /> WAIVER OF OUR RIGHT 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 not enforce <br /> our right against the person or organization named in the Schedule. (This agreement applies only to the extent that <br /> you perform 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 <br /> work described in the Schedule. <br /> The additional premmum for this endorsement shall be 2 % of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> SCHEDULE <br /> PERSON OR ORGANIZATION JOB DESCRIPTION <br /> ANY PERSON OR ORGANIZATION WHERE <br /> WAIVER OF OUR RIGHT TO <br /> RECOVER IS PERMITTED BY LAW AND IS <br /> REQUIRED BY WRITTEN <br /> CONTRACT PROVIDED SUCH CONTRACT WAS <br /> EXECUTED PRIOR TO DATE <br /> OF LOSS <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 01-01-25 Policy No. ZAWC19792801 Endorsement No. <br /> Insured LYONS SECURITY SERVICE, INC. Premium $ INCL. <br /> Insurance Company ARCH INDEMNITY INSURANCE COMPANY <br /> Countersigned By <br /> DATE OF ISSUE: 01-01-25 <br /> ©1998 by the Workers'Compensation Insurance Rating Bureau of California. All rights nesarved. <br /> From the WCIRB's California Workers'Compensation Insurance Forms Manual O 1999. <br /> I <br />