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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 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 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 />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 $ gsn nn <br />Schedule <br />Person or Organization Job Description <br />ALL ORGANIZATIONS FOR WHOM THE WAIVER OF SUBROGATION IS ALL CALIFORNIA OPERATIONS <br />ISSUED <br />A 't® <br />�Q.V$17 K <br />V�SP Oki P� <br />�51g�ar <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 08/0312014 Policy No. 2200062195 -141 Endorsement No. 1 <br />Insured SOUTH COAST LIGHTING & DESIGN INC Premium $ <br />Insurance Company Countersigned by <br />Oak River Insurance Company <br />WC 99 04110A <br />(Ed 07 -07) <br />