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Attachment Code: D608629 Certificate ID: 18427412 <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br /> ENDORSEMENT-CALIFORNIA <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 o %of the California workers'compensation premium <br /> otherwise due on such remuneration. <br /> SCHEDULE <br /> Person or Organization Job Description <br /> WHERE A WAIVER OF OUR RIGHT TO RECOVER FROM <br /> OTHERS IS REQUIRED BY WRITTEN CONTRACT, <br /> SUCH ADDITIONAL ENTITIES SHALL BE <br /> CONSIDERED AUTOMATICALLY SCHEDULED BY THE <br /> COMPANY. <br /> INDIVIDUALLY SCHEDULED WAIVERS SHALL NOT BE <br /> CONSTRUED TO OVERRIDE NOR NEGATE THIS <br /> BLANKET 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 12/31/2029 Policy No. LD59047370 Endorsement No. <br /> Insured UNITED SITE SERVICES, INC. Premium $ Included <br /> Insurance Company Safety National Casualty Corporation <br /> Countersigned By <br /> WC 04 03 06(04 84) Page 1 of 1 <br /> o 1998 by the Workers'Compensation Insurance Rating Bureau of California. All rights reserved. <br />