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BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />Thi s endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different <br />date is indicated below. <br />(The following "attaching clause"need be completed only when this endorsement is issued subsequent to preparation of the policy). <br />Thi s endorsement,effective <br />Issued to <br />By <br />We have a right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce <br />our right against any person or organization with whom you have a written contract that requires you to obtain this <br />agreement from us,as regards any work you perform for such person or organization. <br />The additional premium for this endorsement shall be __%of the total estimated workers compensation premium for <br />this policy. <br />ANY PERSON OR ORGANIZATION TO WHOM YOU BECOME OBLIGATE D TO W AIVE YOUR RIGHT S OF <br />RECOVERY AGAINST, UN DER ANY CONTR ACT OR AGREEMENT YOU ENTER INTO P RIOR TO THE <br />OCCURRENCE OF LOSS <br />WC 04 03 61 Countersigned by ____________________________________________ <br />(Ed. 11/90) Authorized Representative <br />07/01/2026 12:01 AM forms a part of Policy No. WC 051665050 CA <br />ADP TotalSource DE IV, Inc. <br />5800 Windward Parkway <br />Alpharetta, GA 30005 <br />L/C/F: <br />Hanson Bridgett LLP <br />425 MARKET ST <br />Fl 26 <br />San Francisco, CA 941050000 <br />AIU Insurance Company <br />Docusign Envelope ID: 8B1A83C1-5D3E-8229-81C5-784070B121B4