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Workers' Compensation and Employers' Liability Policy Named InsuredEndorsement Number Cbssfuu!Cvtjoftt!Tfswjdft-!Jod/ Policy Number M0D0G!HMPCBM!QPXFS!HSPVQ-!JOD/ 23171!XPPETJEF!BWF Symbol:Number: D81116252 MBLFTJEF-!DB!:3151 Policy PeriodEffective Date of Endorsement 60203133 6020313360203134 TO Issued By (Name of the Insurance Company) Bdf!Bnfsjdbo!Jotvsbodf!Dp/ Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequentto thepreparation of the policy. CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT applies only to the insurance provided by the policy because California is shown in Item This endorsement 3.A. of the Information Page. We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily injury arising out of theoperations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating theremuneration of your employees while engaged in the work described in the Schedule. Schedule 1.() Specific Waiver Name of person or organization: Y ( ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2.Operations: 3.Premium: JODMVEFE The premium charge for this endorsement shall be percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. JODMVEFE 4.Minimum Premium: _______________________________________ Authorized Agent WC 99 03 22