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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 04 03 06 (Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- <br />CALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a <br />different date is indicated below. <br />(The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) <br />This endorsement, effective on 1/1/2025 at 12:01 A.M. standard time, forms a part of <br />(DATE) <br />Policy No. WC 1052003-10 Endorsement No. <br />of the <br />(NAME OF INSURANCE COMPANY) <br />issued to Ancon Marine <br />Premium (if any) $ <br />Authorized Representative <br />We have the right to recover our payments from anyone I iable for an i njury covered by this pol icy. 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 % of the California workers' compensation pre- <br />mium otherwise due on such remuneration. <br />Schedule <br />Person or Organization <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 FOR <br />THAT PERSON AND/OR <br />ORGANIZATION <br />WC 252 (4-84) <br />WC 04 03 06 (Ed. 4-84) <br />Job Description <br />ALL CA OPERATIONS <br />Page 1 of 1 <br />