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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br />enforce our right against the person or organization named in the Schedule. (This agreement applies only to the <br />extent that 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 <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be 2% of the California workers' compensation premium <br />otherwise due on such remuneration. <br />SCHEDULE <br />PERSON OR ORGANIZATION JOB <br />ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION <br />NAMED INSURED HAS AGREED BY WRITTEN <br />CONTRACT TO FURNISH THIS WAIVER <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: 08/01/2023 Policy No. 7600024638231 Endorsement No. 001 <br />Insured: Learn Backhoe and Underground Inc <br />Premium $ INCL. <br />Insurance Company: Everest Premier Insurance Company <br />Countersigned By: <br />- 1998 by the Workers' Compensation Insurance Rating Bureau of California. AS rights reserved. <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. <br />