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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 our <br />right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform <br />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 work <br />described in the Schedule. <br />The additional premium for this endorsement shall be _____% of the California workers' compensation premium otherwise <br />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 />Endorsement Effective Policy No.Endorsement No. <br />Insured <br />Insurance Company <br />Countersigned By <br />WC 04 03 06 (Ed 04-84) <br />APPLIES AS BLANKET WAIVER <br />FOR THOSE HAVING A WRITTEN <br />CONTRACT WITH THE POLICY- <br />HOLDER REQUIRING WOS FOR <br />WC POLICYHOLDER EMPLOYEES. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />2 <br /> WD3-A427457-10 <br /> <br />MASSACHUSETTS BAY INSURANCE COMPANY <br /> <br />DocuSign Envelope ID: 8ED90C61-FB1E-42A9-A36D-120CE7F5D38F