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<br />This endorsement changes the policy to which it is attached and is 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 11-01-23 Policy No. WC128085 Endorsement No. <br />Insured LIVERMORE VALLEY PERFORMING ARTS CENTER Premium $ Incl. <br />Insurance Company SiriusPoint America Insurance Company <br />Countersigned By <br /> <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 />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <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 against 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 obtain this agreement 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 />The additional premium for this endorsement shall be 0% of the California workers’ compensation premium otherwise <br />due on such remuneration. <br />SCHEDULE <br />PERSON OR ORGANIZATION JOB DESCRIPTION <br />Any person or organization as <br />Required by written contract <br />within states covered under this <br />policy. <br />Docusign Envelope ID: 7F1930DB-9FA0-4AA5-A678-8E5639235556