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FEB 20,2015 9 :15AM 9492166855 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />No, 2993 P 21/21 <br />WC 99 0410A (Ed 07.07) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA <br />BLANKET BASIS <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We unit 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 />The additional premium for this endorsement shall be 2.00 % of the total policy premium otherwise due on such <br />remuneration. <br />The minimum premium for this endorsement is $ 35090_ <br />Schedule <br />Person or Organization Job Description <br />ALL ORGANIZATIONS FOR WHOM THE WAIVER OF SUBROGATION IS ALL CALIFORNIA OPERATIONS <br />ISSUED <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The Information belowis required only when this endorsementls Issued subsequentto preparation of the policy.) <br />Endorsement Effective 0 810 312 01 4 Policy No. 2200062196.141 <br />Insured SOUTH COAST LIGHTING & DESIGN INC <br />Insurance Company Countersigned by <br />Oale River Insurance Company <br />WC 99 0410A <br />(Ed 07.07) <br />Endorsement No. 1 <br />Premium $ <br />RECEIVE: N0.3654 02/20 /2015 /FRI 10:04AM <br />