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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 10 (Ed 01 -07) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA <br />BLANKET BASIS <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 />The additional premium for this endorsement shall be 2.00 % of the California workers' compensation premium otherwise <br />due on such remuneration. <br />The minimum premium for this endorsement is $ 350.00 <br />Schedule <br />Person or Organization Job Description <br />ALL ORGANIZATIONS FOR WHOM THE WAIVER OF SUBROGATION IS ALL CALIFORNIA OPERATIONS <br />ISSUED <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 08.131;2008 Policy No. 2200013354 -082 Endorsement No. 1 <br />Insured CULBERTSON ADAMS & ASSOCIATES, INC. Premium $ <br />insurance Company Countersigned by 6' .44� Xlii? 08 <br />Oak River Insurance Company <br />WC 99 04 10 <br />(Ed 01 -07) <br />