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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 09 06 <br />...._ _..._... (Ed. 0404) <br />WAIVER OF OUR RIGHT TO RECOVER PROM OTHERS ENDORSEMENT—CALIFORNIA <br />We have the right to recover our payments from anyone (table far an Injury covered by this policy. We will not enforce our right <br />againstthe portion or organization named in the Schedule. (This agreement applies only to the extent that you perform wort <br />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,,,_0.00L_%of the Callfamla workers' compeneallon premium othermse <br />due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />Any Principal wherein such waiver has <br />Been included before loss as part of a contractual <br />Undertaking by the Named Insured. <br />Notes: <br />1, This andorsement may be used to waive the comp nys right of subrogation against named third Paribas wit may be responsible for an <br />injury. <br />2, The sentence In O Is optional with the company. It emits the endorsement to apply omy to speolito lobs of the insured, and only to the <br />extom that the Insured Is required to obtain this walver. <br />This endorsement changes the pDlicy to which it Is attached and Is aHaative on the date Issued unloss otherwise stated, <br />(The Information below Is required only when this endorsement to Issued subsequent to preparation of the pollcy,) <br />Endorsement Effective 7/112019 Policy No. WCA2010633-12 Endorsement No. <br />Insured: Insurance Company: Grout Divide Ina. Co. <br />Oceen Blue Environmamal Services, Inc. `I <br />Cauniemignod By <br />0 <br />R�VIEWED:.SY .G/ ,UNICE HEFZ)»pI,A PGI, O f <br />