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Master's Refreshment Services (2019-2020 WC)
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12/29/2020 8:29:58 PM
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8/10/2020 9:47:35 AM
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General 2 - Date
8/10/2020
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce <br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that <br />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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be 5 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />PERSON OR ORGANIZATION <br />CITY OF RIVERSIDE <br />3900 MAIN STREET <br />RIVERSIDE CA 92522 <br />SCHEDULE <br />JOB DESCRIPTION <br />BOTTLED WATER <br />CITY OF RIVERSIDE <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 />Endorsement Effective 02/19/2020 Policy No. 7600012026191 <br />Insured MASTER S REFRESHMENT SERVICES <br />Insurance Company EVEREST PREMIER INSURANCE COMPANY <br />Countersigned By <br />-1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. <br />INSURED COPY <br />Endorsement No. 004 <br />Premium $ INCL. <br />
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