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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 04 84 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT - 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 the <br />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 in <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be 0.00% of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />Any person or organization as required in writing by contract or agreement prior to loss. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy) <br />Endorsement Effective <br />07/01 /2023 <br />Insured <br />Ocean Blue Environmental <br />Services, Inc. <br />Insurance Company: <br />Great Divide Insurance Company <br />Policy No. <br />WCA2040736 10 <br />Countersigned <br />by <br />Endorsement No. <br />WC 04 03 06 04 84 1998 by the Workers' Compensation Insurance Rating Bureau of Califor <br />All rights reserved. From the WCIRB's California Workers' Compensa <br />Insurance Forms Manual 2001. <br />Premium <br />77 <br />1tWe MmVewdDf blm <br />RenEw & NVRovw8r. <br />A-qu Acw44 , <br />® <br />Risk Management Spea list 'h <br />