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WORKERS COMP <br /> WC 04 03 06 04 84 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <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 2 %of the California workers' compensation premium <br /> otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> ANY PERSON/ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A <br /> WRITTEN CONTRACT WHERE A CONDI TION OF THIS CONTRACT REQUIRES <br /> YOU TO OBTAIN THIS AGREEMENT. THIS ENDORSEMENT IS EFFECTIVE <br /> ONLY WHERE PERMITTED BY STATUE OR REGULATION. <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 /> Endorsement Effective 6/22/2025 Policy No. ACPWC013079630195 Endorsement No. <br /> Insured Superior Property Services, Inc. Premium <br /> Insurance Company Countersigned By <br /> Nationwide Mutual Insurance Company <br /> WC 04 03 06 04 84 Page 1 of 1 <br /> ACPWC013079630195 LBXI INSUREDS COPY 47 0001533 <br />