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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />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 <br />enforce our right against the person or organization named in the Schedule. <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 2.001% of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Associated <br />Job <br />Person or Organization Job Description Premium <br />Blanket Waiver of Subrogation 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 />(The information below is required only when this endorsement Is issued subsequent to preparation of the policy.) <br />Endorsement Effective 07/01/2019 Policy No. SCW0095811901 Endorsement No. <br />Insured Butler Engineering, Inc. Insurance Company American Premium <br />Automobile Insurance Company <br />Countersigned By 1 i0 AqI AI'ITROVCIN <br />�r��°""'' ><ra:rrreNr DiuisioN <br />WC 04 03 O6 <br />(Ed, 04-84) <br />kA�NCIN'E'R. VILLLAREAL <br />