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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />MACRO-Z-TECHNOLOGY COMPANY <br />Policy Number <br />Symbol: WCF Number: 54309538 <br />Policy Period <br />Effective Date of Endorsement <br />10/01/2021 TO 10/01/2022 <br />10/01/2021 <br />Issued By (Name of Insurance Company) <br />FEDERAL INSURANCE <br />Insert the policy number. The remainder of the Information Is to be completed only when this endorsement Is Issued subsequent to the re oration of the ollcy. <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of <br />the Information Page. <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, but this waiver applies only with respect <br />to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract <br />to obtain this waiver from us. <br />You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the <br />work described in the Schedule. <br />Schedule <br />1. ( ) Specific Waiver <br />Name of person or organization: <br />( X ) Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this <br />waiver. <br />2. Operations: <br />ALL OPERATIONS <br />3. Premium: <br />The premium charge for this endorsement shall be 1.0 percent of the California premium developed <br />on payroll in connection with work performed for the above person(s) or organization(s) arising out of the <br />operations described. <br />4. Minimum Premium: $0 <br />Authorized Representative <br />.�-. kNuMas;reriwfkith4stan <br />6 Nenova:er: <br />RizkMana9enmlClmi(efA(dc <br />WC 90 03 75 (05118) _ _ _ <br />