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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4-84) <br />©1998 by the Workers’ Compensation Insurance Rating Bureau of California. All rights reserved. <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT −−−−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 />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 />Policy No. Endorsement No. <br />Insurance Company <br />Countersigned By <br />RLI Insurance Company <br />All persons or organizations that are party to a contract that <br />requires you to obtain this agreement, provided you executed <br />the contract before the loss. <br />Jobs performed for any person or organization that you <br />have agreed with in a written contract to provide this <br />agreement. <br />PSW0004075PSW0004371 <br />Docusign Envelope ID: 49ECECC2-8C93-8CE6-8042-4993E89E1D99