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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />CopNPoirrt. <br />Insurance Companies <br />COPPERPOINT • ALASKA NATIONAL <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET <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 you <br />perform work under a written contract that requires you to obtain this agreement from us). <br />Schedule <br />Anyone for whom you have agreed to provide this Waiver subject to the terms of the endorsement <br />This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued <br />at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when <br />this endorsement is issued subsequent to commencement of the policy. <br />Endorsement Effective 12/01/2024 Policy No. WC1025483 <br />Insured CWE <br />Insurance Company Pacific Compensation Insurance Company <br />WC 99 03 15 A <br />(Ed. 05-2023) <br />Endorsement No. <br />Premium $ 566.00 <br />Countersigned by <br />Authorized Representative <br />Contains Copyrighted material of WCIRB, used with permission <br />