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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 0410 C <br />(Ed. 01-19) <br />WAIVER OF OUR RIGHT TO RECOVER FFRROOMBOTHERS ENDORSEMENT-CALIFORN(A <br />SLAN <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. (This agreement applies only to the extent that you <br />perform work under a written contract that requires you to obtain this agreement from us.) <br />The additional premium for this endorsement shall be calculated by applying a factor of 2% to the total manual <br />premium, with a minimum Initial charge of $350, then applying all other pricing factors for the policy to this calculated <br />charge to derive the final cost of this endorsement <br />Tbla agreement shall not operate directly or indirectly to benefit anyone not named In the Schedule. <br />Schadulo <br />BlanketWalvar <br />PersoolOrganlzation Blanket Waiver —Any parson or organization forwhom the Named Insured has <br />agreed by written contract to furnish this waiver. <br />Job Description Waiver Premium (prior to adjustments) <br />All CA Operations 1817.00 <br />This andorsement changes the policy to whl:h It is attached and Is effective on the data issued unless otherwlse stated. <br />((he Information below Is raqulmd oniywhon this ondomomerd Is Issuedsubsequent to preparation of the policy.) <br />Endarsemant Etfectiva: oaloamov PogryNW HYWC2113735 Endorsement Na.: <br />Insured: Premium S <br />Insurance Company: Cypress insurance Company <br />Counterslgnad by <br />WC 9911410 C <br />(Ed. 01-19) <br />ru.t nr�r D. <br />,z �.�. ', ReneaID 6 MvRav®Br: <br />%u f�resda, <br />�RrsQMaru9e�mnOeiul Aitle <br />