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. „- 'm <br /> ill <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> WAIVER OF OUR RIGHT TO RECOVER FROM <br /> OTHERS ENDORSEMENT - CALIFORNIA <br /> Policy Number: 57 WEC AN1 MI-1 Endorsement Number: 003 <br /> Effective Date: 04/16/25 Effective hour is the same as stated on the Information Page of the policy. <br /> Named Insured and Address: WE ARE GROUNDSWELL <br /> 1801 E EDINGER AVE STE 115 <br /> SANTA ANA CA 92705 <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 otherwise due <br /> on such remuneration. <br /> SCHEDULE <br /> Person or Organization Job Description <br /> Any person or organization for whom you are required by written contract or agreement to obtain this waiver of rights from <br /> us <br /> Countersigned by <br /> Authorized Representative <br /> Form WC 04 03 06 (1) Printed in U.S.A. <br /> Process Date: 04/16/25 Policy Expiration Date: 10/01/25 <br />