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Big Ben, Inc. <br />POLICY NUMBER: ACPWC3100135937 <br />� i t�•� � lR��f/L�Z IN��Y�i Q�f/L�/i IN��Y�: <br />WC 00 03 13 <br />(Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br />enforce our right against the person or organization named in the Schedule. (This agreement applies only to the <br />extent that you perform work under a written contract that requires you to obtain this agreement from us.) <br />This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br />Schedule <br />Name: Any person or organization from whom you are required to waive your right to recover <br />under a written contract or agreement in effect prior to any loss or damage <br />Address: 4790 Irvine Blvd. #105-404 Irvine, CA 92620 <br />Description of Waiver: Any person or organization from whom you are required to waive your right to <br />recover under a written contract or agreement in effect prior to any loss or damage <br />pne 01101 <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 7/01/2021 - 7/01/2022 Policy No. ACP WC 3100135937 Endorsement No. <br />Insured Big Ben Inc. Premium <br />Insurance Company Nationwide Mutual Insurance Countersigned by <br />WC000313 <br />©1983 National Council on Compensation Insurance. <br />ACP WC 3100135937 <br />Nationwide Mutual Insurance <br />1 00001 0000000000 19108 0 N 8e5c73f9-8132-4027-93f0-3fc3ffff90a2 <br />n", <br />& APPRoveo sr. <br />�-, <br />at <br />�Rmli <br />A&—.g—1 Cl eri-lA do <br />0027020044349734038690680273250 <br />