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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed. 04-84) <br />CALIFORNIAWAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT1 <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 <br />you 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 <br />work described in the Schedule. <br />The additional premium for this endorsement shall be 2 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />SCHEDULE <br />PERSON OR ORGANIZATION JOB DESCRIPTION <br />ANY PERSON(S) OR ORGANIZATION(S) <br />WITH WHOM YOU HAVE AGREED TO SUCH <br />WAIVER, IN A VALID WRITTEN CONTRACT <br />OR WRITTEN AGREEMENT THAT HAS BEEN <br />EXECUTED PRIOR TO LOSS <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 03-15-24 Policy No. WCC349341A <br />Insured A —TECH CONSULTING INC <br />Endorsement No. <br />Premium $ INCL. <br />Insurance Company NATIONAL CASUALTY COMPANY <br />Countersigned By E RAManaganentDMslcn <br />°� f ' REVIEWED & APPROVED BY. <br />Aezv <br />1" Risk Management Specialist <br />© 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. y NJ <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. <br />Insured Copy <br />