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POLICY NUMBER: WCA204889510 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> WC 04 03 06 04 84 <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br /> ENDORSEMENT - CALIFORNIA <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. (This agreement applies only to the <br /> extent that 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 <br /> the work described in the Schedule. <br /> The additional premium for this endorsement shall be 0.00% of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization <br /> Any person or organization as required in writing by contract or agreement prior to loss. <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 Policy No. Endorsement No. <br /> 01/01/2026 WCA2048895 10 <br /> Insured Premium <br /> FCS International, Inc. <br /> Insurance Company: Countersigned <br /> by <br /> Great Divide Insurance Company <br /> WC 04 03 06 04 84 1998 by the Workers'Compensation Insurance Rating Bureau of California. Page 1 of 1 <br /> All rights reserved. From the WCIRB's California Workers'Compensation <br /> Insurance Forms Manual 2001. <br />