Laserfiche WebLink
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />Countersigned by <br />Authorized Representative <br />Form WC 04 03 06 (1) Printed in U.S.A. <br />Process Date:03/01/24 Policy Expiration Date:03/01/25 <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />Policy Number:57 WE OL6HF8 Endorsement Number: <br />Effective Date:03/01/24 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: COATING SPECIALISTS AND INSPECTION SERVICES DBA: CSI SERVICES, INC.. <br />12223 HIGHLAND AVE STE 106-579 <br />RANCHO CUCAMONGA CA 91739 <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our <br />right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br />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 work <br />described in the Schedule. <br />The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due <br />on such remuneration. <br />SCHEDULE <br />Person or Organization Job Description <br />Any person or organization for whom you are required by written contract or agreement to obtain this waiver of rights from <br />us <br />DocuSign Envelope ID: 127FE52A-CAEF-4879-B943-68F42EA8FF9D