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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — 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 "attached clause" need be completed only when this endorsement is issued subsequent to <br />preparation of the policy.) <br />This endorsement, effective on September 01, 2024 <br />(DATE) <br />Policy No. 406-04-54-43-0006 <br />of the Atlantic Specialty insurance Company <br />(NAME OF INSURANCE COMPANY) <br />issued to E . J . WP tRD, INC. <br />Premium (if any) $ <br />at 12:01 A.M. standard time, forms a part of <br />Endorsement No. <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 2.00 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />ALL PERSONS OR ORGANIZATIONS ON FILE WITH <br />THE INSURED <br />WC 252 (D4 84) Copyright 1984, Intact Insurance Group USA LLC <br />E-INSURED <br />