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Workers' Compensation and Employers' Liability Insurance Policy <br />Waiver of Our Right to Recover From Others Endorsement - California <br />WC 04 03 06 <br />If the following information is not complete, refer to the appropriate Schedule attached to the policy. <br />Insured: Bellecci & Associates Policy Number: 57WEGAD4C78 <br />Producer: Dealey, Renton & Associates Effective Date: 07/01/2019 <br />Schedule <br />Person or Organization <br />Job Description <br />ALL PERSONS OR ORGANIZATIONS THAT ARE PARTIE TO A CONTRACT THAT REQUIRED <br />YOU TO OBTAIN THIS AGREEMENT, PROVIDED YOU EXECUTED THE CONTRACT BEFORE <br />THE LOSS <br />Additional Premium % <br />We have the right to recover our payments from any- <br />one liable for an injury covered by this policy. We will <br />not enforce our right against the person or organization <br />named in the Schedule. (This agreement applies only <br />to the extent that you perform work under a written <br />contract that requires you to obtain this agreement <br />from us.) <br />You must maintain payroll records accurately segre- <br />gating the remuneration of your employees while en- <br />gaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be <br />the percentage, as shown in the Schedule applicable to <br />this endorsement, of the California workers' compen- <br />sation premium otherwise due on such remuneration. <br />This Form must be attached to Change Endorsement when issued after the policy is written. <br />One of the Fireman's Fund Insurance Companies as named in the policy <br />Secretary <br />WC0403064-84 <br />P sident <br />