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250 <br />Blanket <br />0007 <br />06/01/2024 <br />XWS (25) 63 08 26 33 <br />CALICO CENTER <br />Ohio Security Insurance Company 19291 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 79 <br />(Ed. 01-13) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT <br />- CALIFORNIA <br />WC 99 06 79 <br />(Ed. 01-13) <br />2013Liberty Mutual Insurance <br />Includes copyrighted material of WCIRB,with its permission. <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 agreement <br />from us.) <br />You must maintain payroll records accurately segregating the remuneration of your employees while en- <br />gaged in the work described in the Schedule. <br />The additional premium for this endorsement is $. <br />Schedule <br />Person or Organization <br />Job Description <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless <br />otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective Endorsement No. <br />Policy Effective Premium <br />State <br />Policy No. <br />Insured <br />Insurance Company <br />Countersigned by ___________________ <br />Docusign Envelope ID: DCF2A2AA-9651-4643-B4A3-B3BE2F88E341