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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 1/1/2026 at 12:01 A.M. standard time, forms a part of <br /> (DATE) <br /> Policy No. WC 1052003-11 Endorsement No. <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 liable for an i njury covered by this pol icy. We will n of <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 Job Description <br /> ALL PERSONS AND/OR ALL CA OPERATIONS <br /> ORGANIZATIONS THAT <br /> ARE REQUIRED BY <br /> WRITTEN CONTRACTOR <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) Page 1 of 1 <br />