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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />We have the right to recover our payments from anyone I iable for an injury covered by this policy. We will not enforce our right <br />against the person or organization named in the Schedule. (Thies agreement applies only to the extent that you perform work under <br />a written contract that requires You to obtain this agreement frorn 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 otherwise due on Such <br />remuneration. <br />Person or Organization Job Description <br />Any person or organization as req&ed by written contract. <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 3/7/2025 Policy No. SWC1540465 Endorsement No. 0 <br />Insured Golden Meters Service, Inc. Premium $ 12,721 <br />Insurance Company Security National Insurance Company <br />Countersigned by <br />WC 04 03 06 <br />(Ed. 04-84) <br />