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Alaska National <br />INSURANCE COMPANY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA <br />We have the right to recover our payments from <br />anyone liable for an injury covered by this policy. We <br />will not enforce our right against the person or <br />organization named in the Schedule. (This <br />agreement applies only to the extent that you perform <br />work under a written contract that requires you to <br />obtain this agreement from us.) <br />Person or Organization <br />Blanket waiver: <br />Any persons or organizations for whom the <br />Insured, has agreed by written contract, to <br />furnish this waiver. <br />You must maintain payroll records accurately <br />segregating the remuneration of your employees while <br />engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be <br />2 % of the California workers' compensation <br />premium otherwise due on such remuneration. <br />SCHEDULE <br />Job Description <br />This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date <br />issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required <br />only when this endorsement is issued subsequent to commencement of the policy. <br />Endorsement Effective 04/01/2024 <br />Insured Mariposa Landscapes, Inc. <br />Countersigned By ,/ taw E. SchmWifeia <br />Policy No. 24D WS 12057 <br />Endorsement No. 6 <br />M' <br />x.kn+a.gonmrok�� <br />pf none, &APPa�ev.- <br />AfeA <br />ANEW Risk Management Spedalist <br />WC 04 03 06 (04 84) <br />81187869 1 24-25 we - tu. I narianaa Padilla [ 7/29/2024 11:50A] ats (ear) I Page 2 of 2 <br />