Orange County NC Website
Browse       Search
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. <br />Countersigned by <br />Authorized Representative <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />4320 W KENNEDY BLVD <br />TAMPA FL 33609 <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 />Policy Number:10 WB AR7J14 Endorsement Number: <br />Effective Date:05/12/24 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address:TVG-MGT Holdings, LP <br />Form WC 04 03 06 (1) Printed in U.S.A. <br />Process Date: Policy Expiration Date:05/12/25 <br />Docusign Envelope ID: B9D098A3-ADE5-4D27-B060-F08A595B7E7D