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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT-CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will <br />not enforce our right against the person or organization named in the Schedule. (This agreement applies <br />only to the extent that you perform work under a written contract that requires you to obtain this <br />agreement from us.) <br />You must maintain payroll records accurately segregating the remuneration of your employees while <br />engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be 0 % of the California workers' compensation <br />premium otherwise due on such remuneration. <br />SCHEDULE <br />Person or Organization Job Description <br />WHERE A WAIVER OF OUR RIGHT TO <br />RECOVER FROM OTHERS IS REQUIRED BY <br />WRITTEN CONTRACT, SUCH ADDITIONAL <br />ENTITIES SHALL BE CONSIDERED <br />AUTOMATICALLY SCHEDULED BY THE <br />COMPANY. <br />INDIVIDUALLY SCHEDULED WAIVERS SHALL <br />NOT BE CONSTRUED TO OVERRIDE NOR <br />NEGATE THIS BLANKET WAIVER. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the <br />policy.) <br />Endorsement Effective 1/1/2021 Policy No. LDS4045504 Endorsement No. <br />Insured MISSION LINEN SUPPLY Premium $ INCL. <br />Insurance Company Safety National Casualty Corporation <br />WC 04 03 06 (04 84) Page 1 of 1 <br />© 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />Attachment Code: D471832 <br />Certificate ID: 15085893 <br />t 11�1.,11.IF_A REVIEWD]6M Rav®BMm%pncnEDMdv: <br />f� R. V.ttfaut <br />Risk Management Analyst <br />