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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 99 03 04 (Ed. 7- 08) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy <br />unless a different date is indicated below. <br />(The following "attaching clause" need to be completed only when this endorsement is issued subsequent to preparation of the <br />policy.) <br />This endorsement, effective on 05/01/2020 at 12:01 A. M. standard time, forms a part of <br />(DATE) <br />Policy NO. 54309689 of the Federal Insurance Company <br />Issued t0 South Coast Mechanical, Inc. <br />South Coast Electrical. Inc. <br />Endorsement No. <br />Authorized Representative <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will <br />not enforce our right against the person or organization named in the Schedule. The additional premium for <br />the blanket waiver offered by this endorsement shall be 0.00 % of total California premium. <br />Schedule <br />Person or Organization <br />Blanket as required by written contract. <br />WC 99 03 04 (Ed. 7-08) <br />Job Description <br />Blanket as required by written contract. <br />RldrMnugemarE DiWdwr <br />REVIEWM& Aevaav® fir <br />Risk �, F�GN� i;. V:UicllfG <br />® Risk Management Analyst <br />nI'1111I 1 '11.-li JMa _c, I,VI R I o -,a a1 1,1/21 ." a' 1 t ,"_ iS 12aoe 2f 0_ 2, <br />This certificate cancels and supersedes Aru previousl, issued ce tif- aces. <br />