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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />Palp Inc. DBA Excel Paving Company <br />Policy Number <br />Symbol: WCF Number:54310181 <br />Policy Period <br />Effective Date of Endorsement <br />6/1/2021T06/1/2022 <br />6/1/2021 <br />Issued By (Name of Insurance Company) <br />FEDERAL INSURANCE <br />Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the olicy�._ _ <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of <br />the Information Page. <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, but this waiver applies only with respect <br />to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract <br />to obtain this waiver from us. <br />You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the <br />work described in the Schedule. <br />Schedule <br />1. ( ) Specific Waiver <br />Name of person or organization: <br />( X) Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this <br />waiver. <br />2. Operations: <br />ALL <br />3. Premium: <br />The premium charge for this endorsement shall be 1.0 percent of the California premium developed <br />on payroll in connection with work performed for the above person(s) or organization(s) arising out of the <br />operations described. <br />4. Minimum Premium: $0 <br />WC 90 03 75 (05/18) <br />Authorized Representative <br />RLkManagemallxviaion <br />RENEWED it APPROVED BY: <br />® R6k Management Malyst <br />