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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 79 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />- CALIFORNIA <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. (This agreement applies <br />only to the extent that you perform work under a written contract that requires you to obtain this agreement <br />from us.) <br />You must maintain payroll records accurately segregating the remuneration of your employees while en- <br />gaged in the work described in the Schedule. <br />The additional premium for this endorsement is $ 250 <br />Schedule <br />Person or Organization <br />AS PER CONTRACT OR WRITTEN AGREEMENT WITH YOU. <br />Job Description <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective 06/08/2021 <br />Policy Effective 06/08/2021 <br />State <br />Policy No. XWS (21) 59 13 88 90 <br />Insured NATIONAL CORROSION, INC. <br />Endorsement No. 0002 <br />Premium See Schedule <br />Insurance Company Ohio Security Insurance Company <br />Countersigned by <br />WC 99 06 79 <br />(Ed. 01-13) <br />© 2013 Liberty Mutual Insurance <br />Includes copyrighted material of WCIRB,with its permission. <br />19291 <br />.' I�vmv.En6 rmao.mar. <br />%au P[cwft <br />Risk Mnug��ertpmulNtle <br />