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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 rlght to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our <br />right agalnst the person ororganization 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 Daic 0 3 / 0 1 / 2 0 2 2 Policy No, SATISO488700 Endorsement No. <br />PollcyEffectiveDate: 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 wMmgne toniPan <br />WC 04 03 06 g aanarrso&APP@ovw By., <br />(Ed, 4-84) A"*0# <br />Mal <br />ltl#i MTnaetetnunt SpflcF,wst <br />