2020/05/16 Western A/V, Inc. Insurance DeclarationsWORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 04 03 08
(Ed_ 4-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA
e have the right to recover our pi�yrnents from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule_ (This agreement applies only to the extent that
you perform work under a written contract that requires ycrr to obtain this agreement from us.)
You crust mairitain payroll records accurately segregating the remuneration of your employees while engaged in the
work described In the Schedule_
The additional premium for this endorsemsnt shall be
otherwise due on such remuneration.
F—emgrivr_Q[g anizatio
CI^'Y OF MENIFEE & ITS OFFICERS
EMPLOYEE£, AGENTS &
F4UTHORIZED VOLT-TI+]TEERS
?9844 npACtN !fib
PRUIPRE CA 9258f7-£539
=% of the California workers' compensaban premium
Schedule
Job Oescrip,ig
CO-NTFACT: $I04 CODE 8742
This endorserreent charges the polioy to which it is attached and is effective on the date issued unless otherwise stated
[fife informtion below is required only when this endorsement is issued subsequent to greillaralion of the pdky.)
ErtdorsementEffedive 01/g1/20
Insured WPST:,:RN A/V
1552 N HrhTPV R ST STX 2
ORANGE CA 92867-355,i
Policy Ne. ` 2 -Gx- S'V6 -1 Endorsement No.
Insurance Company state Farm Fire and Casual.-y Company
Countersigned By
WC040306
(Ed. 4-84) 100772Z 124292.2 0i-25-21)19