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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 person-n <br /> work under a written contract that requires you to obtain this agreement fromus.) <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 Califomia workers'compensation premium otherwise due <br /> on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> Any person or organization for whom Blanket Waiver of Subrogation. <br /> the named insured has agreed by <br /> written contract to furnish this waiver. <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 11/08/2024 Policy No. PSC10701340202 Endorsement No.1 <br /> Coverage Dates: 11/01/2024—11/01/2025 Premium $Incl. <br /> Insured J and A Engineering Corporation <br /> Carrier Name/Code: Palomar Specialty Insurance A <br /> WC 04 03 06 <br /> (Ed. 4-84) Countersigned by <br /> ©1998 by the Worker's Insurance Rating Bureau of California. All rights reserved. <br />