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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 <br /> (Ed.4-84) <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 <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 0% of the California workers' compensation pre-mium <br /> otherwise due on such remuneration. <br /> Schedule <br /> Person or Organization Job Description <br /> ALL PERSONS AND/OR <br /> ORGANIZATIONS THAT <br /> ARE REQUIRED BY <br /> WRITTEN CONTRACT OR <br /> AGREEMENT WITH THE <br /> INSURED, EXECUTED <br /> PRIOR TO THE <br /> ACCIDENT OR LOSS, <br /> THAT WAIVER OF <br /> SUBROGATION BE <br /> PROVIDED UNDER THIS <br /> POLICY FOR WORK <br /> PERFORMED BY YOU <br /> FOR THAT PERSON <br /> AND/OR ORGANIZATION. <br /> INSURED: SCAN Group <br /> POLICY#:WC869903801 <br /> POLICY PERIOD: 07/01/2026 TO 07101/2026 <br /> WC 252(4-84) <br /> WC 04 03 06(Ed.4-84) Page 1 of i <br />