§ 2269.4. California Approved Form Endorsements no. 4.

CALIFORNIA

APPROVED FORM NO. 4

Endorsement Agreement Limiting and Restricting This Insurance

If this policy is issued to an individual or to a husband and wife either as individuals or as a partnership, the insurance under this policy is limited as follows:

It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE:

Relatives Not Insured

As respects injury (or death resulting therefrom) sustained by any of the following relatives of the employer and spouse, or of either, i.e., spouse, child by birth or adoption, stepchild, grandchild, son-in-law, daughter-in-law, parent, stepparent, parent-in-law, grandparent, brother, sister, stepbrother, step-sister, half-brother, half-sister, brother-in-law, sister-in-law, uncle, aunt, nephew or niece. IF at the time of injury such relative (1) resides in the household of the employer and spouse or of either, or (2) is a child under the age of 12 years, unless such relative is included specifically by name in the schedule of operations of the declarations or is specifically insured by name in an endorsement attached to this policy.

Nothing in this endorsement contained shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations of this endorsement.

Applicable to and forming part of Policy No. ________________

Issued by the _______________________________________________

To_____________________________________ of __________________

Dated at _____________________this_______day of ______199____

Countersigned _______________________________________________

FAILURE TO SECURE THE PAYMENT OF FULL

COMPENSATION BENEFITS FOR ALL EMPLOYEES AS

REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION

OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION

OF A WORK STOP ORDER, LARGE FINES AND OTHER

SUBSTANTIAL PENALTIES

(Labor Code Section 3710.1, et seq.).

HISTORY

1. Amendment filed 10-4-60; designated effective 1-1-61 (Register 60, No. 21).

2. Amendment filed 9-18-67; designated effective with respect to all policies and endorsements with an effective date falling on or after April 1, 1968 (Register 67, No. 38).

3. Amendment filed 1-21-81; effective thirtieth day thereafter (Register 81, No. 4).

Note

Note: Authority cited: Sections 11732, 11732.1, and 11734, Insurance Code. Reference: Articles 2 and 3 of Chapter 3, Part 3, Division 2, Insurance Code.