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Workers Compensation And Employers Liability Insurance <br />Policy Endorsement <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. (This agreement applies only to the <br />extent that you 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 <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be Waiver of Subrogation Percent of the California workers' <br />compensation premium otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />PER ATTACHED SCHEDULE OF HOLDERS <br />All other terms and conditions of the policy remain unchanged. <br />This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, <br />takes effect on the Policy Effective date of said policy at the hour stated in said policy, unless another <br />effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy <br />unless another expiration date is shown below. <br />Form No: WC 04 03 06 (04-1984) <br />Endorsement Effective Date: <br />PQQgg p <br />EM <br />Rg��tSkMP.� � 4✓177/ 1 1r I <br />Policy No: 6057544401 <br />Effective Date: 4/1/2020 <br />® Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual 0 2001. <br />