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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 02i01/2025 <br />(DATE) <br />Policy No. WC2925201 11 <br />of the <br />issued to <br />Premium (if any) $ <br />at 12:01 A.M. standard time, forms a part of <br />Endorsement No. <br />(NAME OF INSURANCE COMPANY) <br />Authorized Representative <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 % of the California workers' compensation pre- <br />mium otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />Any Person or Organization that requires <br />You to waive your Rights of Recovery, in a <br />written contract or agreement with the Named <br />Insured that is executed prior to the accident <br />or loss. <br />Job Description <br />WC 04 03 06 (Ed. 4-84) Page 1 of 1 <br />