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Docusign Envelope ID: 31630204-995B-4DCC-A316-0219109A1493 <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4-84) <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 not enforce our right <br />against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a <br />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 work described <br />in the Schedule. <br />The additional premium for this endoresement shall be 2% of the California workers' compensation premium otherwise due on <br />such remuneration. <br />Schedule <br />Person or Organization Job Description <br />CITY OF PLEASANTON <br />P.O. BOX 520 <br />PLEASANTON, CA 94566 <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: l/l/2024 - l/l/2025 Policy No.: CWC71949-1529 Endorsement No.: <br />Insured: South East Employee Leasing Services, Inc. (LCF) Insurance Company: State National Insurance Company, Inc. <br />Richard Smith dba Bay Area Tree Specialists <br />Countersigned By: v <br />