Laserfiche WebLink
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 />All persons or organizations that are party to a Job performed for any person or organization that you <br />contract that requires you to obtain this have agreed with in a written contract to provide this <br />agreement, provided you executed the contract agreement. <br />before a loss <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Policy No. PSW0003014 Endorsement No. Endorsement Effective 3/3/2024 <br />Insured Kayuga Solution, Inc. Insurance Company RLI Insurance Company <br />DocuSign Envelope ID: 5C9E3D6D-78BE-43C5-A919-929E9BC66BC0