PIPE & PLANT SOLUTIONS, INC. - Laserfiche WebLink

WC 90 03 75 (05/18) Workers' Compensation and Employers' Liability Policy Named Insured PIPE AND PLANT SOLUTIONS, INC. 225 3RD. ST. OAKLAND CA 94607 Endorsement Number Policy Number Symbol:WCF Number:(22)5430-99-65 Policy Period 06-01-2022 TO 06-01-2023 Effective Date of Endorsement 06-01-2022 Issued By (Name of Insurance Company) FEDERAL INSURANCE Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. 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 person or organization named in the Schedule, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1. ( ) Specific Waiver Name of person or organization: WHERE REQUIRED BY WRITTEN CONTRACT. (X ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: ALL 3. Premium: The premium charge for this endorsement shall be 1.0 percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium:$0 Authorized Representative DocuSign Envelope ID: DD7E61F4-D64F-4FC6-A1EB-1FDD2F05B052