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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <br />WC 04 03 06 <br />(Ed. 04-84) <br />We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not enforce our right <br />against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work <br />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 0.02 % of the California workers' compensation premium otherwise due <br />on such remuneration. <br />Schedule <br />Person Or Organization Job Description <br />Any person or organization as required by written contract <br />within states covered under this policy. <br />This endorsement changes the policy to which it is attached and Is effective on the date issued unless otherwise staled. <br />(The information below is required only when this endorsement Is Issued subsequent to preparation of the Polley.) <br />Endorsement Effective 01/24/2024 <br />Insured Embee Computer Design Inc <br />WC 04 03 06 <br />(Ed. 04-84) <br />Policy No. WC PI 710827-000 Endorsement No. <br />Insurance company The Pie Insurance Company <br />Countersigned By <br />Risk Mvwgono tDmsb t <br />RevEwmSAPPa mBr. <br />® <br />RM Management Speaalist <br />