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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />.. _.__....._.._...,_ _ (Ed 04-64) <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 _0.00_% of the California workers' compensation premium otherwise <br />due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />Any Principal wherein such waiver has <br />Been included before loss as part of a contractual <br />Undertaking by the Named Insured. <br />Notes: <br />1. This endorsement maybe used to waive the company's right or subrogation age In at named third parties who may be responsible for an <br />injury. <br />2. The sentence In( ) is optional with the company. It limits the endorsement to apply only to specific jobs of the insured, and only to the <br />extent that the insured is required to obtain this waiver. <br />This endorsement changes the policy to which It is attached and Is effective on the dale Issued unless otherwise stated. <br />(The Information below is required only when this endorsement Is issued subsequent to preparation of the polity.) <br />Endorsement Effective 7/1/2017 Policy No. VVCA201 Sa$3-11 Endorsement No. <br />Insured:Ocean Blue Environmental Services, Inc. insurance Company: Great. Dlyiagns. Cp <br />�(- <br />r(,/ �. <br />Countersigned BY <br />REVIEWED BY: ----L✓�'�—Y�——EUN€CF HERLbIA (P. jyFl <br />