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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 />Person or Organization <br />Any person or organization for whom <br />the named insured has agreed by <br />written contract to furnish this waiver. <br />Schedule <br />Job Description <br />Blanket Waiver of Subrogation. <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 />