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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC D403 06 <br />(Ed. 4-84) <br />WAIVER OF OUR RIGHTTO 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 <br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br />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 work <br />described In the Schedule. <br />The additional premium due for this endorsement shall be 2% of the California workers compensation premium otherwise <br />due on such remuneration OR MP $350.00. <br />Schedule <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 />01/01/2021 - 01/01/2022 <br />Policy No. EIG4675559-00 <br />Countersigned by <br />Endorsement No. WC2021-01 <br />Rink Mowge eraDlAs[an <br />rR�EMEWED&pAP crvemY: B <br />rAHYiiA.( ram. Val 44d <br />®' Risk Management Analyst <br />