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Workers'Compensation and Employers'Liability Policy 1 <br /> Named Insured Endorsement Number <br /> MEHTA MECHANICAL COMPANY, INC. DBA:MMC INC <br /> 5901 FRESCA DRIVE, Policy Number <br /> LA PALMA,CA 90623 Symbol:wLR Number:G58$32674 <br /> Policy Period Effective Date of Endorsement <br /> 10/1/2024 TO 10/1/2025 10/1/2024 <br /> Issued By(Name of the Insurance Company) <br /> Ace American Insurance Company <br /> Insert the policy number.The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. <br /> This endorsement changes the policy to which it is attached and Is effective on the date issued unless otherwise stated. <br /> CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br /> This endorsement applies only to the insurance provided by the policy because California is shown in Item <br /> 3.A. of the Information Page. <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy. We will <br /> not enforce our right against the person or organization named in the Schedule, but this waiver applies <br /> only with respect to bodily injury arising out of the operations described in the.Schedule, where you are <br /> required by a written contract to obtain this waiver from us. <br /> i You must maintain payroll records accurately segregating the remuneration of your employees while <br /> l engaged in the work described in the Schedule. <br /> i <br /> Schedule <br /> 1. { ) Specific Waiver <br /> Name of person or organization: <br /> (x) Blanket Waiver <br /> Any person or organization for whom the Named Insured has agreed by written contract to furnish this <br /> waiver. <br /> 2. Operations: <br /> ALL CALIFORNIA OPERATIONS <br /> 3. Premium: <br /> The premium charge for this endorsement shall be 1.0 percent of the California premium developed <br /> on payroll In connection with work performed for the above person(s)or organization(s) arising out of the <br /> operations described. <br /> 4. Minimum Premium: $0 <br /> 1�*112 <br /> Authorized Agent <br /> WC 90 03 75(05/18) <br />