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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 04.84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right <br />against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work <br />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 2.00% of the California workers' compensation premium otherwise due on <br />such remuneration. <br />Schedule <br />Person or Organization <br />Any person or organization as required by written contract <br />Notes: <br />Job Description <br />1. This endorsement may be used to waive the company's right of subrogation against named third parties who may be responsible for an <br />injury. <br />2. The sentence In ( ) Is optional with the company. It limits the endorsement to apply only to specific jobs of the insured, and only to the <br />extent that the insured is required to obtain this waiver. <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 910112024 Policy No. CTP1002817 Endorsement No. <br />Insured T.E Roberts, Inc. Insurance Company CorePointe Insurance Company <br />Countersigned By <br />