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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br /> <br /> (Ed. 04-84) <br /> <br />WC 04 03 06 <br />(Ed. 04-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENTCALIFORNIA <br /> <br /> <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 /> <br />You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work <br />described in the Schedule. <br /> <br />The additional premium for this endorsement shall be _____% of the California workers’ compensation premium otherwise due <br />on such remuneration. <br /> <br /> <br />Schedule <br /> <br />Person or Organization Job Description <br /> <br /> Any person or organization where waiver of our right <br /> to recover is permitted by law and is required by written contract <br /> was ececuted prior to date of loss. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Notes: <br /> <br />1. This endorsement may be used to waive the company’s right of subrogation against named third parties who may be responsible for an <br />injury. <br /> <br />2. The sentence in ( ) is optional with the company. It limits the endorsement to apply only to specific jobs of the insured, and only to the <br />extent that the insured is required to obtain this waiver. <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 /> <br />Endorsement Effective Policy No. Endorsement No. <br />Insured Insurance Company <br /> <br /> <br /> <br /> Countersigned By <br /> <br />7/1/2025 71WCI1993502 <br />O'Grady Paving, Inc.Arch Insurance Company <br />86009460 | OGRAPAV-C1 | 25-26 GL Auto WC XS | Daylin Rodriguez | 6/27/2025 3:33:56 PM (PDT) | Page 10 of 11 <br />Docusign Envelope ID: 5619FDA5-F294-4609-A6B6-614BED03B25C