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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 0❑03 0❑1111d. ❑1111❑❑ <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 10/01/2024 at 12:01 A.M. standard time, forms a part of <br />DAT-- <br />Policy ❑o. WC 5646573 - 01 <br />of the <br />issued to Leed Electric, Inc. <br />Premium if any <br />❑ndorsement ❑o. <br />Zurich American Insurance Company <br />CAME] OF I OS❑RA❑C❑ COMPA-Y- <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 <br />enforce our right against the person or organization named in the Schedule. :This agreement applies only to the <br />event that you perform wor❑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 wor❑described in the Schedule. <br />The additional premium for this endorsement shall be ❑ of the California worEOrs❑compensation pre[] <br />mium otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />ALL P❑RSO❑S A❑DOOR <br />ORGA❑IZATIO❑S THAT AR❑ <br />R❑Q❑IR❑D BY WRITT❑❑ CO❑TRACT <br />OR AGR❑❑M❑❑T WITH TH❑ 111S❑R❑D, <br />❑❑❑C❑T❑D PRIOR TO TH❑ ACCID❑❑T <br />OR LOSS, THAT WAIV'_1R OF <br />S❑BROGATIO❑ B❑ PROVID❑D ❑❑D❑R <br />THIS POLICY FOR WORD P❑RFORM❑D <br />BY YO❑ FOR THAT P❑RSO❑ A❑DOOR <br />ORGA❑IZATIO❑ <br />Job Description <br />ALL CA OP❑RATIO❑S <br />WC 2E2 1111=o <br />WC 0❑ 03 0❑ mod. 0=0 <br />Page 1 of 1 <br />