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INSURED <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 Endorsement No. <br />Insured Premium $ <br />Insurance Company <br />Countersigned By <br />07/01/2025 Policy No. WPL 2163388 <br />INSURANCE COMPANY OF THE WEST <br />BLACK TIE TRANSPORTATION LLC INCL. <br /> <br />WC 99 06 34 <br />(Ed. 8-00) <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 34 <br />(Ed. 8-00) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET <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 />The additional premium for this endorsement shall be % of the total California Workers’ Compensation premium <br />otherwise due. <br />Schedule <br />Person or Organization Job Description <br /> 2 <br />ANY PERSON OR CALIFORNIA <br />ORGANIZATION FOR OPERATIONS ONLY <br />WHOM THE NAMED <br />INSURED IS REQUIRED <br />UNDER WRITTEN <br />CONTRACT TO FURNISH <br />THIS WAIVER <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Docusign Envelope ID: 2C9A65BB-21B7-4E3B-A5B5-F713B3B31D24Docusign Envelope ID: 8D82D9D4-0EDC-4063-A4B1-305FA902188EDocusign Envelope ID: 0D1BA1AB-EE6C-4FC0-8B30-14755F8114EE