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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed. 4-84) <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 <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 2 % of the California workers' compensation <br />premium otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />With respect to all employees subject to the <br />workers' compensation laws of the state of <br />California, any person or organization for whom <br />the Named Insured has agreed by written <br />contract to furnish this waiver. <br />This policy is subject to a minimum charge of $250 for the issuance of waivers of subrogation <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 />This endorsement, effective 11/06/2020 <br />Policy No. EIG 2562084 02 <br />Issued to PROTECTION AMERICA INC <br />Premium <br />Countersigned at <br />WC 04 03 06 <br />(Ed. 4-84) <br />at 12:01 AM standard time, forms a part of <br />Of the EMPLOYERS ASSURANCE CO. <br />Carrier Code 00919 <br />Endorsement No. <br />� ��,i nrvisiort <br />o n B y: ReAEv/ED 6 APPROVED BY: <br />AuthorizE A'I�Il ,]azi {wee caars <br />l Risl(Manage tCieiial Aide <br />© 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights res <br />