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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />Countersigned by <br />Authorized Representative <br />(1) Printed in U.S.A.Form WC 04 03 06 <br />Policy Expiration Date: <br />WAIVER OF OUR RIGHT TO RECOVER FROM <br />OTHERS ENDORSEMENT - CALIFORNIA <br />Endorsement Number:Policy Number: <br />Effective Date: Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: <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 2 % of the California workers' compensation premium otherwise due <br />on such remuneration. <br />SCHEDULE <br />Person or Organization Job Description <br />Any person or organization from whom you are required by written contract or agreement to obtain this waiver of rights <br />from us <br />57WEGZJ8917 <br />07/29/2024 <br />Carlson Management,Inc.DBA:CM,Inc. <br />1551 7th Avenue <br />San Francisco,CA 94122 <br />07/29/2025 <br />Docusign Envelope ID: 7076786B-4077-4AE2-89F3-0DA257129D51