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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed. 04-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA <br />We have the right to-reeover ourpayments from anyone liable for an injury covered by this policy. We will not enforce out right <br />against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under <br />a written contract.that requlres you to obtain this agreementfiom us.) <br />You must maintain payroll records accurately segregating the reinnneratien of ycirr employees while ongagod in the walk <br />desoribed in the Schedule <br />The additional premium for this endorsement shall be 2%of the California workers' compensation premium otherwise due on such <br />remuneration. <br />Schedule <br />Person or Organization Job Description <br />Any person or organization as required by written contract.. <br />APPROVED <br />By Cynthia Mora at 1:58 pm, Nov 27, 2024 <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 3/7/2024 Policy No. SWC1481:305 Endorsement No. 0 <br />Insured Golden Meters Service, Inc. Premium°$ 13,251 <br />Insurance Company Security National Insurance Company <br />Countersigned by -- <br />WC 04 03 06 <br />(Ed, 04-84) <br />