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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />Policy Number: 72 WEC GI4348 Endorsement Number: <br />Effective Date: 12/17/21 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: DIXON RESOURCES UNLIMITED <br />3639 MIDWAY DRIVE STE B345 <br />SAN DIEGO CA 92110 <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 <br />perform 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 work <br />described in the Schedule. <br />The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due <br />on such remuneration. <br />001:l=1 1qM <br />Person or Organization <br />Job Description <br />Any person or organization for whom you are required by written contract or agreement to obtain this waiver of rights from <br />us <br />Countersigned by <br />Form WC 04 03 06 (1) Printed in U.S.A. <br />Process Date: 11/07/21 <br />wrwoi� <br />AnEwensnrmw®er. <br />•�'� %u �rte.ar <br />RukfvNnage�mnClai�al Aitle <br />Policy Expuduon U4LU. ILf I fizz <br />