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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 040306 <br />(Ed. 04-84) <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 enforce <br />our right aganst 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 obtan this agreement from us.) <br />You must mantan 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 INCL % of the California workers ' compensation premium <br />otherwise due on such remuneration. <br />SCHEDULE <br />PERSON OR ORGANIZATION JOB DESCRIPTION <br />ANY PERSON OR ORGANIZATION WHERE <br />WAIVER OF OUR RIGHT TO RECOVER IS <br />PERMITTED BY LAW AND IS REQUIRED <br />BY WRITTEN CONTRACT PROVIDED SUCH <br />CONTRACT WAS EXECUTED PRIOR TO <br />DATE OF LOSS <br />ALL JOBS UNDER CONTRACT <br />This endorsement changes the policy to which it is attached and i s 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 04/01/2024 Policy No. ZAWCl9413907 Endorsement No . <br />Insured AMERICAN ASPHALT REPAIR Premium $ INCL. <br />Insurance Company ARCH INSURANCE COMPANY <br />Countersigned By _____________ _ <br />© 1998 by the Workers' Compensation Insurance Rating Bureau of California . All rights reserved . <br />From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. <br />DocuSign Envelope ID: E96A4C74-2FC7-4968-986D-B86E1F2596BA