Hanover
Insurance Group.
W23 H991741 1001130
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA 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 person or dant aires you to the ed reine tales to ere are or re Yes bed the schedull records accurately segregating the remuneration of your employees while engaged in the work The additional premium for this endorsement shall be ? % of the California workers' compensation premium otherwise due on such remuneration.
Schedule
Person or Organization Job Description
APPLIES AS A BLANKET WAIVER FOR THOSE HAVING A
WRITTEN CONTRACT WITH THE POLICYHOLDER REQUIRING WOS
FOR WC POLICYHOLDER EMPLOYEES
The indration betaw is required on to when this endarsement is issued subsequento preparation of the poise stated.
Endorsement Effective Policy No. W23-H991741-00 Endorsement No.
Insured
Insurance CompanyALLMERICA FINANCIAL BENEFIT INSURANCE
Countersigned By
WC 04 03 06 (Ed 04-84)