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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br /> (Ed. 04-84) <br /> WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA <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 /> You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work <br /> described in the Schedule. <br /> The additional premium for this endorsement shall be 0.02 % of the California workers' compensation premium otherwise due <br /> on such remuneration. <br /> Schedule <br /> Person Or Organization Job Description <br /> Any person or organization as required by written contract <br /> within states covered under this policy. <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 08/19/2025 Policy No. WC PI 2800953-000 Endorsement No. <br /> Insured TRIANGLE DECON SERVICES Insurance Company The Pie Insurance Company <br /> Countersigned By <br /> WC 04 03 06 <br /> (Ed. 04-84) <br />