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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 04 03 06 (Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />This endorsement changes the policy to which It Is attached effective on the Incoptlon date of the policy unless a <br />different date Is Indicated below. <br />(Tho following'ottaching clause' need be completed only when this endorsement Is Issued subsequent to prapamtion of the policy.) <br />This endorsement, effective on <br />Policy No. WC 102078301 <br />of the <br />issued to Vanir Construction management, Inc <br />Premium (if any) $ <br />at 12:01 A.M. standard time, forms a part of <br />Endorsement No. 1 <br />Zurich Insurance Company <br />Authorized Representative <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br />enforce our right against the person or organization named In the Schedule, (This agreement applies only to the <br />extent that 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 <br />the work described In the Schedule. <br />The additional premium for this endorsement shall be <br />mium otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />% of the California workers' compensation pre - <br />Job Description <br />Any person or organization for whom you are required by written contract or agreement to obtain this <br />waiver of rights from us <br />WC 252 (4-64) Page 1 of 1 <br />WC 04 03 06 (Ed. 4-64) <br />