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i <br /> 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 - <br /> CALIFORNIA <br /> We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce <br /> our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br /> 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 the <br /> work described in the Schedule. <br /> The additional premium for this endorsement shall be % of the California workers' compensation premium otherwise <br /> due on such remuneration. <br /> SCHEDULE <br /> PERSON OR ORGANIZATION JOB DESCRIPTION <br /> Any Person or Organization for which the insured has <br /> agreed by written contract executed prior to loss to <br /> furnish this 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 06-25-25 Policy No. CSWC05049600 Endorsement No. <br /> lnsured CALI STATE PAVING INC. Premium $ Incl . <br /> Insurance Company Clear Spring Property and Casualty Company <br /> Countersigned By <br /> ©1998 by the Workers'Compensation Insurance Rating Bureau of California. All rights reserved. <br /> From the WCIRB's California Workers' Compensation Insurance Forms Manual©'1999. <br /> ASURED <br />