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Attachment Code: D565978 Certificate ID: 16059509 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our <br />right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br />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 work <br />described in the Schedule. <br />The additional premium for this endorsement shall be _*_% of the California workers' compensation premium otherwise <br />due on such remuneration. <br />Person or Organization <br />Job Description <br />WHERE YOU ARE REQUIRED BY WRITTEN CONTRACT TO <br />OBTAIN THIS AGREEMENT FROM US, PROVIDED THE <br />CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF <br />LOSS TO WHICH THIS WAIVER APPLIES. IN NO INSTANCE <br />SHALL THE PROVISIONS AFFORDED BY THIS <br />ENDORSEMENT BENEFIT ANY COMPANY OPERATING <br />AIRCRAFT FOR HIRE. <br />*The premium charge for this endorsement shall be 2% of the premium developed in the State of California, but not less <br />than $500 policy minimum premium. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 2/1/2022 Policy No. T10220329 Endorsement No. 23 <br />Insured Rincon Consultants, Inc. Policy Effective Date 2/1/2022 <br />Insurance Company StarStone National Insurance Company <br />Countersigned By <br />WC 04 03 06 <br />(Ed. 4-84) <br />Rii Ito geaeaol,: . <br />CW 998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. '%a�°:, �net�o6 Mrflwmar. <br />flak Marw9mm, ClAical Ai,l� <br />