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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 01-2008) <br />Countersigned by: ______________________ <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 <br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that <br />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 the <br />work described in the Schedule. <br />The additional premium for this endorsement shall be % of the California worker's compensation premium <br />otherwise due on such remuneration. <br />Schedule <br />Job DescriptionPerson or Organization <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 />Endorsement Effective: File No.: Carrier Policy No.: <br />Premium: <br />Carrier No.: Insured: <br />Insurance Company: State National Insurance Company <br />Endorsement: WC 04 03 06 <br />Edition:01/08 <br />Agency: AmWINS Specialty Casualty Solutions, LLC / 1 <br />10/29/2024 1 AMX-200-0209-005 <br />5 <br />Oasis Outsourcing, LLC; Certified Safe Driver, Inc. <br />City of Pleasanton <br />P.O. Box 520 <br />Pleasanton , CA 94566 <br />20164389 | OasisOutsourcingInc MCP (CA) AMX2000209005 | MR | 10/29/2024 11:34:12 AM EDT | Page 2 of 2 <br />Docusign Envelope ID: B3FAA998-1EBE-4DEB-8E46-8D19BAD6D74D