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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 CALIFORNIA (Blanket) <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 ________ % of the California workers’ compensation premium otherwise <br />due on such remuneration. <br />0.020000 <br />Schedule <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 />Countersigned By <br />Endorsement Effective Date: Endorsement No.: 1 <br />Insured Name: Bay Area PL Services Insurance Company: Midwest Employers Casualty <br />Company <br />POLICY NUMBER: BNUWC0162784 <br />Policy Number:BNUWC0162784 <br />State Description <br />CA Any party with whom the insured agrees to waive subrogation in a written contract. <br />Docusign Envelope ID: EAC72FF0-2F63-4ADB-9A2E-1E009CC6908F