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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br /> (Ed. 4-84) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 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 <br /> premium otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> Any person or organization for whom the Named <br /> Insured has agreed by written contract executed prior <br /> 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 Policy No. Endorsement No. <br /> Insured Insurance Company <br /> Countersigned by <br /> WC 04 03 06 <br /> (Ed. 4-84) <br /> ©1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. <br /> From the WCIRB's California Workers' Compensation Insurance Forms Manual©2001. <br /> Page 1 of 1 <br /> 9016877001 06/26/2025 <br /> Sentry Casualty Company <br /> 1 00002 0000000000 25177 0 N 56797fd8-f089-4c5b-8629-6b9e3729c5df <br />