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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 WE OL6H1 H <br />Effective Date:09/01/2024 <br />Named Insured and Address:15ordtln0o So ooDve <br />San Luis Obispo CA 93401 <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 <br />Job Description <br />Any person or organization from whom you are required by written contract or agreement to obtain this waiver of rights <br />from us <br />Countersigned by <br />Authorized Representative <br />Form WC 04 03 06 (1) Printed in U.S.A. <br />Policy Expiration Date: 09/01/2025 <br />84347633 124-25 GL/AL/WC/UM/PL I Isabella Sa Ldivar 1 3/13/2025 11:50:56 AM (POT) I Page 12 of 15 <br />