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WORKERS COMPENSATION AND EMPLOYERS LIAE31LI Y INSURANCE POLICY WC 04 03 06 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT --CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury revered by this poiicy. We will not <br />enforce our right against the person or organization named in the Schedule. (Phis agreement applies only to the <br />extent that you perforin work under a written contract that requires you to obtain this agreement from us.) <br />You gust 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 premium <br />otherwise dote on such remuneration. <br />SCHEDULE <br />Person or Organization Jab Description <br />Where a waiver of our right to recover from <br />others is recf+.�ired by written contract, such <br />additional entities shall be considered <br />aultomaticaily scheduled by the Company. <br />Ind?vidually scheduled waivers shall -not be <br />construed to override nor negate this <br />blanket waiver. <br />This endorsement changes the policy to which it is attached and is effective oti the date issued unless otherwise stated. <br />(Che information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement Effective 06/01/2017 Policy No. LDM11046213 <br />Insured GOODWILL 1NDUSTRIES OF 0?RY1,:,1CL CQU'NTY <br />Insurance Company Safety National Casualty Corporation <br />Countersigned By <br />WC 04 03 06 (04 04) <br />Endorsement No. <br />Premium $ included <br />r <br />0 4558 by the Workers' Compensation insurance Rating Bureau of Cali mia. Ail rights reserved. <br />Page 1 of 1 <br />di, <br />