TERI BLACK & COMPANY, LLC (#2025506)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date:02/06/25 Policy Expiration Date:03/19/26 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number:72 WEC ZI2611 Endorsement Number:Effective Date:03/19/25 Effective hour is the same as stated on the Information Page of the policy.Named Insured and Address:TERI BLACK AND COMPANY, LLC 25500 HAWTHORNE BLVD STE 1158 TORRANCE CA 90505 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description Any person or organization for whom you are required by written contract or agreement to obtain this waiver of rights from us Docusign Envelope ID: 70BCFC45-450D-41B4-B90F-9B112E5874A1