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11 /15/2011 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4 -84; <br />- I 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 <br />our 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 <br />work described in the Schedule. <br />The additional premium for this endorsement shall be 2.00% of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />Any person or organization as required by written contract <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />Endorsement Effective 1127/2011 Policy No. SWC1002531 Endorsement No. WC 04 03 06 <br />Insured Landmark Fence Co., Inc. Premium $ <br />Insurance Company Security National Insurance Company Countersigned by <br />5 <br />CBRT NO.: 11659348 Nancy A. Cantero 11/15/2021 9:51:24 AM Pags 3 of 3 <br />