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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4-84) <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br /> <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />This endorsement, effective <br />Policy No. <br />Endorsement No.Issued to <br />Premium <br />By: <br />Carrier Code <br />(Ed. 4-84) <br />Authorized Representative <br />Countersigned at on <br />at 12:01 AM standard time, forms a part of <br />Of the <br />WC 04 03 06 <br />© 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. <br />Schedule <br />Person or Organization Job Description <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 <br />not enforce our right against the person or organization named in the Schedule. (This agreement applies <br />only to the extent that you perform work under a written contract that requires you to obtain this <br />agreement from us.) <br />You must maintain payroll records accurately segregating the remuneration of your employees while <br />engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be _____% of the California workers' compensation <br />premium otherwise due on such remuneration. <br />With respect to all employees subject to the <br />workers' compensation laws of the state of <br />California, any person or organization for whom <br />the Named Insured has agreed by written <br />contract to furnish this waiver. <br />2 <br />This policy is subject to a minimum charge of $250 for the issuance of waivers of subrogation <br />DU-ALL SAFETY LLC <br />00920 <br />EMPLOYERS PREFERRED INS. CO. <br />11/01/2023 <br />22 EIG 2403848 07 <br />DocuSign Envelope ID: D4FD59B7-5718-4765-B842-AC6F6CB082C1DocuSign Envelope ID: 2422988F-1FE6-48E0-ACF9-547C5C40E896