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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC990410C <br />(Ed. 01-19) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA <br />BLANKET BASIS <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 />This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br />Schedule <br />Blanket Waiver <br />Person/Organization Blanket Waiver— Any person or organization for whom 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 1601.00 <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: 10101/2021 PolicyNo.: QUWC202153 Endorsement No.: <br />Insured: Premium $ <br />Insurance Company: Cypress Insurance Company <br />Countersigned by <br />WC 99 04 10 C <br />(Ed. 01-19) <br />