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A <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: 84 WEC BG4S68 Endorsement Number: <br /> Effective Date: 06/20/25 Effective hour is the same as stated on the Information Page of the policy. <br /> Named Insured and Address: TRIPEPI SMITH &ASSOCIATES <br /> PO BOX 52152 <br /> IRVINE CA 92619 <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: 05/11/25 Policy Expiration Date:06/20/26 <br />