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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />TYCO INTERNATIONAL MANAGEMENT COMPANY, LLC <br />9 ROSZEL ROAD <br />Policy Number <br />PRINCETON NJ 08540 <br />Symbol: WLR Number: 048018737 <br />Policy Period <br />Effective Date of Endorsement <br />10 -01 -2014 TO 10 -01 -2015 <br />10 -01 -2014 <br />Issued By (Name of Insurance Company) <br />ACE AMERICAN INSURANCE COMPANY <br />Insert the policy number, The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparat ion of the policy. <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the <br />Information Page. <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, but this waiver applies only with respect to bodily injury arising out <br />of the operations described in the Schedule, where you are required by a written contract to obtain this waiver 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 />Schedule <br />1. ( ) Specific Waiver <br />Name of person or organization: <br />( X ) Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. <br />2. Operations: <br />3. Premium: <br />The premium charge for this endorsement shall be 2.0 percent of the California premium developed <br />on payroll in connection with work performed for the above person(s) or organization(s) arising out of the <br />operations described. <br />4. Minimum Premium : $0 <br />53�� <br />Auffiom dAgent <br />WC 99 03 22 <br />