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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT— CA <br /> This endorsement changes the policy to which it is attached effective on the <br /> inception date of the policy unless otherwise stated. <br /> This endorsement effective on 2/1/2024 at 12:01 am standard times forms a <br /> part of Policy No. WZ3H171505 <br /> of the The Hanover American Insurance Company <br /> issued to: T&B Planning, Inc. <br /> Premium (if any) $ <br /> Authorized Representative <br /> We have the right to recover our payments from anyone liable for an injury covered by <br /> this policy. We will not enforce our right against the person or organization named in <br /> the Schedule. (This agreement applies only to the extent that you perform work under a <br /> written contract that requires you to obtain this agreement from us) <br /> You must maintain payroll records accurately segregating the remuneration of your <br /> employees while engaged in the work described in the Schedule. <br /> The additional premium for this endorsement shall be 2.000% of the California workers' <br /> compensation premium otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization <br /> ANY PERSON OR ORGANIZATION WITH WHOM YOU AGREE IN WRITING TO WAIVE YOUR <br /> RIGHT TO RECOVER AGAINST THEM. YOU MUST AGREE TO THIS WAIVER PRIOR TO THE <br /> DATE OF LOSS <br /> Job Description: Projects as on file with the insured <br /> APPROVED <br /> By Cynthia Mora at 9:04 am, Nov 13, 2024 <br /> WC 252 040 84 <br /> 81908645 1 24-25 GL-AL-UL-WC-PL 1 Sherry Young 1 9/16/2024 8.36(13 AM (PDT) 1 Page 6 of 6 <br />