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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed. 04-84) <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 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 <br />otherwise due on such remuneration. <br />PERSON OR ORGANIZATION <br />% of the California workers' compensation premium <br />SCHEDULE <br />Any person or organization as <br />required by written contract work <br />within the state covered under this <br />policy <br />JOB DESCRIPTION <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 01-01-22 Policy No.WC25205 02 Endorsement No. <br />Insured TSG Enterprises, Inc. Premium $ Incl. <br />Insurance Company Sirius America Ins Co �� ���,//// <br />Countersigned By2&41- �1�'�"`K'S <br />Risk MsrugemmtDiv *n <br />REVfEWED & APPRovm 8y. <br />(c` 1998 by the workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. ~ <br />�� Risk Management Specialist <br />