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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br /> WC 04 03 06 (Ed. 4 84) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br /> ENDORSEMENT-CALIFORNIA <br /> This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different <br /> date is indicated below. <br /> (The following"attaching clause"need be completed only when this endorsement is issued subsequent to preparation of the policy.) <br /> This endorsement, effective on 04/01/2026 at 12:01 A.M. standard time, forms a part of <br /> (DATE) <br /> Policy No. WC 3112664-01 Endorsement No. <br /> of the Zurich American Insurance Company <br /> (NAME OF INSURANCE COMPANY) <br /> issued to Helix Environmental Planning, Inc <br /> Premium (if any) $ <br /> Authorized Representative <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 <br /> 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 in the work <br /> described in the Schedule. <br /> The additional premium for this endorsement shall be % of the California workers' compensation premium otherwise <br /> due on such remuneration <br /> Schedule <br /> Person or Organization Job Description <br /> ALL PERSONS AND/OR ORGANIZATIONS THAT ARE <br /> REQUIRED BY WRITTEN CONTRACT OR AGREEMENT <br /> WITH THE INSURED, EXECUTED PRIOR TO THE <br /> ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION <br /> BE PROVIDED UNDER THIS POLICY FOR WORK <br /> PERFORMED BY YOU FOR THAT PERSON AND/OR <br /> ORGANIZATION. <br /> WC 04 03 06 (Ed. 4-84) Page 1 of 1 <br />