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WC 90 03 75 (05/18) <br />Workers' Compensation and Employers' Liability Policy <br />Named Insured Endorsement Number <br />Policy Period <br />Issued By (Name of Insurance Company) <br />Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. <br />CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A.of <br />the Information Page. <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,but this waiver applies only with respect <br />to bodily injury arising out of the operations described in the Schedule,where you are required by a written contract <br />to obtain this waiver from us. <br />You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the <br />work described in the Schedule. <br />Schedule <br />1.()Specific Waiver <br />Name of person or organization: <br />(X )Blanket Waiver <br />Any person or organization for whom the Named Insured has agreed by written contract to furnish this <br />waiver. <br />2.Operations: <br />3.Premium: <br />The premium charge for this endorsement shall be 1.0 percent of the California premium developed <br />on payroll in connection with work performed for the above person(s) or organization(s) arising out of the <br />operations described. <br />4.Minimum Premium:$0 <br />Authorized Representative <br />Policy Number <br />Symbol: Number: <br />Effective Date of Endorsement <br />12/31/2023 - 12/31/2024 12/31/2023 <br />54309878 <br />Sperber Landscape Companies, LLC <br />ALL OPERATIONS <br />Docusign Envelope ID: 3254F026-A447-4BC0-939B-3E5589DD3A37