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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC ON 04 WSA <br />(Ed. 01-19) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our light <br />against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work <br />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 work <br />described in the Schedule. <br />Blanket Waiver: The additional premium for this endorsement shall be 2% of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Specific Waiver: 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 />Blanket Waiver of Subrogation <br />Schedule <br />Job Description <br />As respects to all CA jobs performed by the named insured during the <br />policy period where by written contract a waiver of subrogation is <br />required prior to the commencement of work. <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: 04/01/2020 <br />Insured Sereno, Michael and Sunseri, <br />Edward dba Sunseri's <br />Policy No.: ON09646 - 01 Endorsement No.: <br />Insurance Company preferred Professional Insurance Company <br />Countersigned By <br />C_J <br />Risk Mr[naganad Divisian <br />REVIEWED&APPROVED By: <br />faaa.o:.r.e R. Mnebd <br />'� Risk Management Analyst <br />Print Date: 3/312020 <br />