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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT--CALIFORNfA <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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be 2 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Person or Organization <br />Schedule <br />Job Description <br />All persons or organizations that are party to a contract that Jobs performed for any person or organization that you <br />requires you to obtain this agreement, provided you have agreed with in a written contract to provide this <br />executed the contract before the loss. agreement. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise staled. <br />(The information below Is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 06-05-2024 Policy No. PSWO001945 Endorsement No. <br />Insured Insurance Company <br />Scott Fazekas & Associates, Inc. RLI Insurance Company <br />Countersigned By <br />p1998 by the Workers' Compensation insurance Rating Bureau of California. All rights reserved <br />orz,N�F RAManagmumtDMslcrn <br />r' REVIEWED & APPROVED BY. <br />x <br />o� tczvac <br />® Risk Management Specialist <br />