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Endorsement Effective: Policy No.: <br />Insured: <br /> WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br /> <br />WC 99 04 10 C <br />(Ed. 01-19) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA <br />BLANKET BASIS <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 against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br />perform work under a written contract that requires you to obtain this agreement from us.) <br /> <br /> <br />The additional premium for this endorsement shall be calculated by applying a factor of 2% to the total manual <br />premium, with a minimum initial charge of $350, then applying all other pricing factors for the policy to this calculated <br />charge to derive the final cost of this endorsement. <br /> This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. <br />Schedule <br />Blanket Waiver <br />Person/Organization <br /> <br />Blanket Waiver Any person or organization for whom the Named Insured has <br />agreed by written contract to furnish this waiver. <br />Waiver Premium (prior to adjustments) <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />Endorsement No.: <br />Premium $ <br />Insurance Company: <br />WC 99 04 10 C <br />Countersigned by ______________________________________ <br /> (Ed. 01-19) <br />Job Description <br />All CA Operations <br />Berkshire Hathaway Homestate Ins Co <br />UNWC004079 <br />7027.00 <br />10/01/201910/01/2020 <br />Universal Site Services, Inc. <br />10/01/202110/01/2022 UNWC40695110-01-2023 <br />DocuSign Envelope ID: 13CAFADC-F4E6-4651-87C8-CD5470196B5C