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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />Policy Number: 72 WN C93100 Endorsement Number: <br />Effective Date: 04/01/2024 Effective hour is the same as stated on the Declarations of the policy. <br />Named Insured and Address: GRISWOLD INDUSTRIES AND SUBSIDIARIES <br />1701 PLACENTIA AVENUE <br />COSTA MESA, CA 92627 <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 2 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />SCHEDULE <br />Person or Organization Job Description <br />ANY PERSON OR ORGANIZATION FROM WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR <br />AGREEMENT TO OBTAIN THIS WAIVER OF RIGHTS FROM US. <br />Countersigned by-�» <br />Au <br />Form WC 04 03 06 Printed in U.S.A. <br />Risk MaiugM9nLDhU1un <br />RenenrD&APPROVEDRY: <br />`1,�L111�1- A+� Awl <br />® R&Managemen[SpedAm <br />