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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 99 03 04 (Ed. 7- 08) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENTCALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy <br />unless a different date is indicated below. <br />(The following "attaching clause" need to be completed only when this endorsement is issued subsequent to preparation of the <br />policy.) <br />This endorsement, effective on 10/31/2021 <br />(DATE) <br />Policy No. 54303295 of the <br />issued to Byrom -Davey, Inc. <br />Endorsement No. <br />at 12:01 A. M. standard time, forms a part of <br />Federal Insurance Company <br />(NAME OF INSURANCE COMPANY) <br />Authorized Representative <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. The additional premium for <br />the blanket waiver offered by this endorsement shall be 0.00 % of total California premium. <br />Person or Organization <br />WHERE REQUIRED BY WRITTEN <br />CONTRACT. <br />WC 99 03 04 (Ed. 7-08) <br />Schedule <br />Job Description <br />WHERE REQUIRED BY WRITTEN <br />CONTRACT. <br />wj�.q�,nuwon <br />IR�nEwm6Ar Or. <br />8jli1111:.1i/_a %au �iezAox <br />IowaRkNMarugeemttOmalNtle <br />