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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4-841 <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 0% of the California workers' compensation pre-mium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization Jab Description <br />ALL PERSONS AND/OR <br />ORGANIZATIONS THAT <br />ARE REQUIRED BY <br />WRITTEN CONTRACT OR <br />AGREEMENT WITH THE <br />INSURED,EXECUTED <br />PRIOR TO THE <br />ACCIDENT OR LOSS, <br />THAT WAIVER OF <br />SUBROGATION BE <br />PROVIDED UNDER THIS <br />POLICY FOR WORK <br />PERFORMED BY YOU <br />FOR THAT PERSON <br />AND/OR ORGANIZATION. <br />INSURED: SCAN Group <br />POLICY #: WC869903800 <br />POLICY PERIOD: 07/01/2024 TO 07/01/2025 <br />WC 252 (4-84) <br />WC 04 03 06 (Ed. 4-84) Page 1 of 1 <br />