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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 79 <br />(Ed. 0 1 -13) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />- CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br />enforce our right against the person or organization named in the Schedule. (This agreement applies only to <br />the extent that you perform 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 <br />in the work described in the Schedule. <br />The additional premium for this endorsement is $ 250. <br />Schedule <br />Person or Organization <br />Where required by contract or written agreement prior to loss and allowed by law. <br />Job Description <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br />stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Issued by Ohio Security Insurance Company 19291 <br />For attachment to Policy No. XWS (26) 59 32 84 73 <br />Issued to PROFESSIONAL SPORTS FIELD <br />MAINTENANCE, INC <br />WC 99 06 79 <br />(Ed. 01-13) <br />Effective Date 10/30/2025 Premium $248.00 <br />© 2013 Liberty Mutual Insurance <br />Includes copyrighted material of WCIRB, with its permission. <br />12/10/2025 XWS (26) 59 32 84 73 Page 12 of 12 <br />