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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 not enforce our <br />right against the person or organization named in the Schedule. (This agreement applies only to the extent that you per- <br />form work under a written contract that requires you to obtain this agreement 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 />The additional premium for this endorsement shall be 0 . 020 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />Blanket Waiver of Subrogation as required by written <br />Job Description <br />contract <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The Information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective Date:03/01/2022 Policy No. SATESO488700 Endorsement No. <br />Policy Effective Date: 03/01/2022 to03/01/2023 Premium$ <br />Insured: Kingdom Causes, Inc <br />DBA: City Net <br />Carrier Name / Code: Service American Indemnity Company <br />Countersigned by wekntarugm>M,ton� <br />WC040306 % Ramerreo&APPROVmaY: <br />(Ed.4-84) D �kro� Aae44 <br />¢I3K ManaQCmnt spaemist <br />z <br />