Orange County NC Website
Browse       Search
DocuSign Envelope ID:7ACADO9D-B318-4AD6-B8E5-CB7B9C2A289F <br /> 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 inception date of the policy unless a <br /> different date is indicated below. <br /> (The following"attaching clause"need be completed only when this endorsement is issued subsequent to preparation of the policy.) <br /> This endorsement, effective on: 04/01/2017 at 12:01 A.M. standard time, forms a part of <br /> Policy No. WC 0112779-02 Endorsement No. <br /> of the: Zurich American Insurance Company <br /> issued to: Stearns, Conrad and Schmidt, Consulting Engineers, Inc. <br /> Premium (if any) $ <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 % of the California workers' compensation pre- <br /> mium otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR <br /> AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF <br /> SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT <br /> PERSON AND/OR ORGANIZATION <br /> WC 252(4-84) <br /> WC 04 03 06(Ed.4-84) Page 1 of 1 <br />