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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 against the <br /> person or organization named in the Schedule.(This agreement applies only to the extent that you perform work under a written contract <br /> 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 described in the <br /> Schedule. <br /> The additional premium for this endorsement shall be %of the California workers'compensation premium otherwise due on such <br /> remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> Any person or organization with whom or with which you have agreed See wording under Person or Organization <br /> in a written contract to waive your right of recovery against,provided <br /> such written contract; <br /> 1. is currently in effect or will be come effective during the term <br /> of this policy;and <br /> 2. was executed and became effective prior to the occurrence <br /> of the injury covered by this policy. <br /> This form only applies in CA. <br /> This endorsement changes the policy to which It Is attached and is effective on the date Issued unless otherwise stated. <br /> Endorsement Effective Policy No.4087479726 Endorsement No. <br /> Insured Insurance Company <br /> Countersigned By <br />