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DATE OF ISSUE: 10-10-24 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <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 10-01-24 Policy No. ;"8$*4 Endorsement No. <br />Insured Premium $ <br />Insurance Company <br />Countersigned By <br />ARCH INSURANCE COMPANY <br />SIERRA NEVADA CONSTRUCTION,INCL. <br /> <br /> 1998 by the Workers’ Compensation Insurance Rating Bureau of California. All rights reserved. <br />From the WCIRB’s California Workers’ Compensation Insurance Forms Manual 1999. <br />WC 04 03 06 <br />(Ed. 04-84) <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />Policy Number : # ;"8$*4 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />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 workers’ compensation premium <br />otherwise due on such remuneration. <br />SCHEDULE <br />PERSON OR ORGANIZATION JOB DESCRIPTION <br />AS AGREED PER WRITTEN CONTRACT OR <br />INCL <br />ALL JOBS UNDER CONTRACT <br />WRITTEN AGREEMENT <br />Mary Hearron <br />Docusign Envelope ID: F9AC9A1A-7D30-43C0-B525-C1635A73245B