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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 - CALIFORNIA <br />(Ed. 04.84) <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 200 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />Any person or organization as required by written contract <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 Date: 07128/2020 <br />Policy Effective Dates: 4712812020 - 07/28/2021 <br />Insured: Si Property Solutions, Inc. <br />Policy No.: CST5019729 Endorsement No. <br />Carrier Name 1 Code: Benchmark Insurance CompanyA <br />WC 04 03 06 Countersigned by <br />(Ed. 04-84) <br />@ Copynght 1984 National Council on Compensation Insurance, Inc. <br />. <br />R;ak Manage i DMsim <br />RwEWEO s�APPROVED BY.' <br />cl'W' <br />i� <br />/ate Pec,-v2 <br />-""-- <br />RiskM..g rmit Cl--IAide <br />