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Attachment Code: D544681 Master ID: 1444909, Certificate ID: 16683669 <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 04 03 06 (Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT— <br />CALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a <br />different date is indicated below. <br />(The following "attaching clause" need be completed only when this endorsement is Issued subsequent to preparation of the policy.) <br />This endorsement, effective on 1/29/2020 at 12:01 A.M. standard time, forms a part of <br />(DATE) <br />Policy No. WC 1868045 - 00 Endorsement No. <br />of the <br />(NAME OF INSURANCE COMPANY) <br />Issued to <br />Premium (if any) $ <br />Authorized Representative <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 % of the California workers' compensation pre- <br />mium otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />All persons and/or organizations - other than manufacturers of <br />asbestos, manufacturers whose component parts include asbestos, or <br />distributors of a product that contains asbestos - that are <br />required by written contract or written agreement with you, <br />executed prior to the accident or loss, that waiver of subrogation <br />be provided under this policy for work performed by you for that <br />person and/or organization. <br />Insured: Alliance Environmental Holdings, LLC <br />REVIEWED & APPROVED <br />By Risk MANAGEMENT DivisiON <br />WC 252 (4-84) Af 9 2020 <br />WC 04 03 06 (Ed. 4-84) <br />Confidential \ Personal Data <br />ANGIE ACEVEdo <br />Page 1 of 1 <br />