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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />Countersigned by <br />Authorized Representative <br />Form WC 04 03 06 (1) Printed in U.S.A. <br />Process Date:01/19/23 Policy Expiration Date:03/01/24 <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />Policy Number:57 WEC RT4859 Endorsement Number: <br />Effective Date:03/01/23 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address:AMADOR-LIVERMORE VALLEY HISTORICAL SOCIETY <br />603 MAIN ST <br />PLEASANTON CA 94566 <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 5 % of the California workers' compensation premium otherwise due <br />on such remuneration. <br />SCHEDULE <br />Person or Organization Job Description <br />The City of Pleasanton, its officers, employees and agents, <br />P.O. Box 520, Pleasanton, CA, 94566 <br />1 <br />Docusign Envelope ID: 6742B2A0-60D2-4A1F-AF7E-DA5218EA169D