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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 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. 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 />(Tice information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />This endorsement, effective 11101 /2021 <br />Policy No. EIG 4581764 02 <br />Issued to DATA TICKET, INC, <br />at 12:01 AM standard time, forms a part of <br />Of the EMPLOYERS PREFERRED INS. CO. <br />Carrier Code 00920 <br />Endorsement No. <br />Premium /% (7 <br />Countersigned at on By: �`— <br />Authorized r' <br />RE <br />AEwEP7 AVPPROVED SYr <br />WC 04 03 06 1 °7 Pew140a <br />(Ed. 4-84) © 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights rese R,k M.—g—t clerical Ade <br />