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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 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 recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right <br /> against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work <br /> 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 2.00%of the California workers' compensation premium otherwise due on <br /> such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> Any person or organization as required by written contract <br /> Notes: <br /> 1. This endorsement may be used to waive the company's right of subrogation against named third parties who may be responsible for an <br /> injury. <br /> 2. The sentence in( )is optional with the company. It limits the endorsement to apply only to specific jobs of the insured,and only to the <br /> extent that the insured is required to obtain this waiver. <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 9/01/2025 Policy No. CTP1004191 Endorsement No. <br /> Insured T.E Roberts, Inc. Insurance Company CorePointe Insurance Company <br /> Countersigned By ��x� <br />