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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />Policy Number: 72 WBC AA411-1 Endorsement Number: <br />Effective bate: 07/01/19 Effective hour Is the same as stated on the Information Page of the policy. <br />Named Insured and Address: Bunnell Enterprises, Inc. <br />5150 E PACIFIC COAST HWY STE 530 <br />LONG BEACH CA 90804 <br />We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not enforce our <br />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 work <br />described in the Schedule.. <br />The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due <br />on such remuneration. <br />F3dtL 79111#I <br />Person or Organization <br />Job Description <br />Any person or organization from whom you are required by written contract or agreement to obtain this waiver of rights <br />from us <br />irauntersigned by <br />Authorized Representative <br />Form WC 04 03 06 (1) Print <br />Process Date: 05/22/19 '� /,may Policy Expiration Date: 07/01/20 <br />5"10863 1 ¢9 Rkg/E3; 119 ESO; '19 EPLI, '19 WC I Liz 9oeboo 1 11/13/20 9 3' 1:24 PM (RSTJ I Page 6 of 6 <br />