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Workers' Compensation and Employers' Liability Policy <br />Named Insured <br />Endorsement Number <br />WOODRUFF SPRADLIN & SMART, APC <br />Policy Number <br />Symbol: Number: 22 7175-05-87 <br />Policy Period <br />Effective Date of Endorsement <br />04/01/2021 TO 04/01/2022 <br />04/01/2021 <br />Issued By (Name of Insurance Company) <br />Federal Insurance Company <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 Policy. <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 the <br />Information Page. <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce <br />our right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily injury <br />arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver <br />from us. <br />You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work <br />described in the Schedule. <br />Schedule <br />1. (0) Specific Waiver <br />Name of person or organization <br />Any person or organization for whom the Named Insured has <br />agreed by written contract to furnish this waiver. <br />(N) Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. <br />2. Operations: <br />ALL CALIFORNIA OPERATIONS <br />3. Premium: <br />The premium charge for this endorsement shall be 1 % percent of the California premium developed on payroll in <br />connection with work performed for the above person(s) or organization(s) arising out of the operations described. <br />4. Minimum Premium: <br />Authorized Representative <br />11 <br />RWW..ge [ a. <br />-_ rhwEWID6AvrnO�m ar: <br />WC 90 03 75 (05/18) +I 7eu Presa <br />rs:xnti,.ge„�„r umUiad, <br />producer Copy <br />