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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> WAIVER OF OUR RIGHT TO RECOVER FROM <br /> OTHERS ENDORSEMENT - CALIFORNIA <br /> Policy Number: 72 WN C93100 Endorsement Number: 16 <br /> Effective Date: 04/01/2025 Effective hour is the same as stated on the Declarations of the policy. <br /> Named Insured and Address: GRISWOLD INDUSTRIES <br /> 1701 PLACENTIA AVENUE <br /> COSTA MESA, CA 92627 <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 2 % of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> SCHEDULE <br /> Person or Organization Job Description <br /> ANY PERSON OR ORGANIZATION FROM WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR <br /> AGREEMENT TO OBTAIN THIS WAIVER OF RIGHTS FROM US. <br /> Countersigned by <br /> Authorized Representative <br /> Form WC 04 03 06 Printed in U.S.A. <br />