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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 04 03 06 (Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- <br />CALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a <br />different date is indicated below. <br />(The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) <br />This endorsement, effective on 10/01/2021 at 12:01 A.M. standard time, forms a part of <br />(DATE) <br />Policy No. WC-3243711-03 <br />of the <br />issued to Leed Electric, Inc. <br />Premium (if any) $ <br />Endorsement No. <br />Zurich American Insurance Company <br />Authorized Representative <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 <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be <br />mium otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />% of the California workers' compensation pre - <br />Job Description <br />ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR <br />AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF <br />SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT <br />PERSON AND/OR ORGANIZATION. <br />WC 252 (4-84) <br />WC 04 03 06 (Ed. 4-84) <br />Rick Management Dbieion <br />I/`�Rentweo 6 APPRav®Br. <br />��� Risk Management Analyst <br />