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Insurance Certificates 2019/20 Burrtec Waste & RecyclingV N Client#: 437902 BURRTWASTE ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE /DD/YYYY) /28/2ozo THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Marsh & McLennan Agency LLC PHONE FAx Marsh & McLennan Ins. Agency LLC -Mn NoExt : Afc, No PO Box 85638 ADDRESS: constructioncerts@marshmma.co.m San Diego, CA 92186 INSURERS) AFFORDING COVERAGE NAIC # INSURER A: Lexington Insurance Company 19437 INSURED Burrtec Waste Group, Inc. 9890 Cherry Avenue Fontana, CA 92335 INSURER B : American Zurich Insurance Company 40142 INSURER C : Navigators Specialty Insurance Company 36056 INSURER D : Liberty Insurance Underwriters, Inc. 19917 INSURER E : Zurich American Ins Co of Illinois 27855 INSURER F : COVERAGES CERTIFICATE NLIMRER- RFVISInN NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUB LTR I R wVD POLICY EFF POLICY EXP LIMITS POLICY NUMBER MMIDD♦'YYYY • MAW D/ A X COMMERCIAL GENERAL LIABILITY X 023627374 D3/01/2019 03/15/2020 EACH OCCURRENCE $1 00O 000 CLAIMS -MADE 5OCCUR PREMISES OF.occurrrence $100,000 X BI/PD Ded:25000 MED EXP (Any one person) $EXCLUDED PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY � PRO LOC GENERAL AGGREGATE PRODUCTS - COMP/OPAGG $2,000,000 $2,000,000 OTHER: $ E AUTOMOBILE LIABILITY X BAP014157402 D3/01/2019 03/15/2026 O BI'NE�D SINGLE LIMIT $2,000 000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ EACH OCCURRENCE $5 00O .000 D3/01/2019 03115/2020 A UMBRELLA LIAB X OCCUR 021391622 X AGGREGATE $5 000 000 EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORFARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? � N / A X WC014157302 03/01/2019 03115/2020 OTH- X PIEARTUTE E.L. EACH ACCIDENT $1000 000 , E.L. DISEASE - EA EMPLOYEE $1 000 000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below SF19EXC8680571C E.L. DISEASE - POLICY LIMIT $1 000 000 C XS of $5M D3/01/2019 03/15/2021 $3M Per Occ/Agg D XS of $8M 100014503905 03/01/2019 03MW2020, $9M Per Occ/Apg DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Job: Operations pertaining to named insured for certholder. City of La Quinta, its elective and appointive boards, commissions, officials, employees, agents and volunteers are additional insureds, primary and non-contributory per endorsements attached. Umbrella/Excess liability follows form of Primary policies. %,am i iri%.rai L rlVLUr-M City of La Quinta SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 78495 Calle Tampico ACCORDANCE WITH THE POLICY PROVISIONS. La Quinta, CA 92253-2839 AUTHORIZED REPRESENTATIVE dT ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S4725607/M4722751 WSADH AC��►�` ADDITIONAL REMARKS SCHEDULE Page 1 of 2 AGENCY Marsh & McLennan Insurance Agency LLC NAMEDINSURED Burrtec Waste Group, Inc. CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, ` FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Named Insured Schedule Burrtec Waste Group, Inc. Burrtec Waste Industries, Inc. Agua Mansa MRF, LLC AVCO Disposal, Inc. Burr Group, LP Burr Group, Inc Burr Properties, LLC Burr Properties, G.P. Burrline, LLC Burrtec Environmental, LLC Burrtec Recovery & Transfer, LLC Burrtec Waste & Recycling Services, LLC Burrtec Retirement Savings Plan Burrtec Waste Industries, Inc. (formerly PSP Waste Services, Inc.) Burrtec Waste Industries, Inc. DBA: Burbank Recycling Burrtec Waste Industries, Inc. DBA: Agua Mansa Recycling & Transfer Co. Burrtec Waste Industries, Inc. DBA: Burrtec Recycling & Transfer Co. Burrtec Waste Industries, Inc. DBA: Burrtec Recycling Center Burrtec Waste Industries, Inc. DBA Coachella Valley Compost Burrtec Waste Industries, Inc. DBA Coachella Valley Transfer Station Burrtec Waste Industries, Inc. DBA Desert Disposal Burrtec Waste Industries, Inc. DBA: East Valley Recycling & Transfer Burrtec Waste Industries, Inc. DBA: Inland Empire Recycling Burrtec Waste Industries, Inc. DBA:Marks Disposal Burrtec Waste Industries, Inc. DBA: Tri-Co Burrtec Waste Industries, Inc. DBA: Tri-County Disposal Burrtec Waste Industries, Inc. DBA: Trico Disposal Burrtec Waste Services, LLC Crestline Disposal Currans Rubbish Disposal, Inc. E. Cole Burr, individually E. Cole Burr, Trustee of the Burr Family Trust EDCO Disposal Edward G. Burr Sandra L. Burr Cole Burr Tracy A. Burr Burr Properties Empire Disposal, LLC Fontana Rubbish Collectors, Inc. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �►�arro. ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Marsh & McLennan Insurance Agency LLC NAMEDINSURED Burrtec Waste Group, Inc. CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Named Insured Schedule Inland BioEnergy, LLC Jack's Disposal, Inc. DBA Yukon Disposal Jack's Disposal, Inc. Kaiser Recycling Corporation KGB Properties, LLC (formerly Burr Girls, LLC Lake Arrowhead Disposal Lucerne Valley Disposal Monte Vista Disposal , Inc. Mountain Disposal Services, Inc. Rancho Disposal Service, Inc. Rialto Services, Inc. Running Springs Disposal TECMEC Maintenance Enterprise, Inc. Tracy A. Burr, individually Tracy A. Burr, Trustee Tri-County Disposal, Inc. Tri-County Disposal, Inc. DBA: Gary's Disposal Victorville Disposal, Inc. West Valley MRF, LLC West Valley Recycling and Transfer, Inc. Yucaipa Disposal, Inc. Desert Properties, LLC Burr Family Trust Yukon Disposal Cal Disposal Co., Inc. Universal Waste Systems, Inc. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD INSURED: Burrtec Waste Group, Inc. POLICY #: 023627374 POLICY PERIOD: 03/01/2019 TO 03/15/2020 PRIMARYINON CONTRIBUTORY ENDORSEMENT This endorsement modifies insurance provided by the policy: Notwithstanding any other provision of the policy to the contrary, the insurance afforded by this policy for the benefit of the Additional Insured shall be primary insurance, but only with respect to any. claim, loss or liability arising out of the Named Insured's operations; and any insurance maintained by the Additional Insured shall be non-contributing, AN other terms and conditions of the policy remain the same. LX9838 (OW05) INSURED: Burrtec Waste Group, Inc. POLICY#: 023627374 POLICY PERIOD: 03/01/2019 ENDORSEMENT LEXINGTON INSURANCE COMPANY TO: 03/15/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED REQUIRED BY WRITTEN CONTRACT A. Section II - Who Is An Insured is amended to include any person or organization you are re- quired to include as an additional insured on this policy by a written contract or written agreement in effect during this policy period and executed prior to the "occurrence" of the "bodily injury" or "property damage." B. The insurance provided to the above described additional insured under this endorsement is limited as follows: 1. COVERAGE A BODILY INJURY AND PROPERTY DAMAGE (Section I - Coverages) only. 2. The person or organization is only an ad- ditional insured with respect to liability arising out of "your work" or "your pro- duct" for that additional insured. 3. In the event that the Limits of Insurance provided by this policy exceed the Limits of Insurance required by the written contract or written agreement, the insurance pro- vided by this endorsement shall be limited to the Limits of Insurance required by the written contract or written agreement. This endorsement shall not increase the Limits of Insurance stated in the Declarations under Item 3. Limits of Insurance pertaining to the coverage provided herein. 4. The insurance provided to such an additional insured does not apply to "bodily injury" or "property damage" arising out of an architect's, engineer's or surveyor's rendering of or failure to render any pro- fessional services including: i The preparing, approving or failing to prepare or approve maps, shop draw- ings, opinions, reports, surveys, field orders, change orders, or drawings and specifications; and ii Supervisory, inspection, architectural or engineering activities. 5. This insurance does not apply to "bodily injury" or "property damage" arising out of "your work" or "your product" included in the "products -completed operatons hazard" unless you are required to provide such coverage by written contract or written agreement and then only for the period of time required by the written contract or written agreement and in no event beyond the expiration date of the policy. Includes copyrighted information of the Insurance Services Offices, Inc. LX9466 (10/03) with its permission. All rights reserved. Page 1 of 2 6. Any coverage provided by this endorse- ment to an additional insured shall be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary or non-contributory basis. C. Subparagraph (1)(a) of the Pollution exclusion paragraph 2.f., Exclusions of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY (Section I - Coverages) does not apply to you if the "bodily injury" or "property damage" arises out of "your work" or "your product" performed on premises which are owned or rented by the additional insured at the time "your work" or "your product" is per- formed. D. In accordance with the terms and conditions of the policy and as more fully explained in the policy, as soon as practicable, each additional insured must give us prompt notice of any "occurrence" which may result in a claim, forward all legal papers to us, cooperate in the defense of any actions, and otherwise comply with all of the policy's terms and conditions. Authorized Representative OR Countersignature (In states where applicable) Includes copyrighted information of the Insurance Services Offices, Inc. LX9466 (10/03) With its permission. All rights reserved. Page 2 of 2 INSURED: Burrtec Waste Group, Inc. POLICY#: 023627374 POLICY PERIOD: 03/01/2019 TO: 03/15/2020 ENDORSEMENT LEXINGTON INSURANCE COMPANY AGGREGATE LIMITS OF INSURANCE - PER LOCATION AMENDMENT AND OVERALL GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the policy: Subject to the Overall General Aggregate Limit stated in Item 3 of the Declarations, the General Aggregate Limit under LIMITS OF INSURANCE (Section III) applies separately to each of your "locations". It is further understood and agreed that the following changes are made to the policy: (1) Item 3, Limits of Insurance in the Declarations is amended by the addition thereto of the following Limit: Overall General Aggregate Limit - $5 , 000, 000 (2) SECTION III -LIMITS OF INSURANCE is amended by the addition thereto of the following paragraph under paragraph 6. 7. The Overall General Aggregate Limit is the most we will pay under Coverages A and B for the sum of all Limits of Insurance as provided in this SECTION III regardless of the number of your "locations"; except for damages because of "bodily injury" and "property damage" included in the "products -completed operations hazard". For the purpose of this endorsement, "locations" means premises involving the same lot, or connecting lots or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. All other terms and conditions remain unchanged. # �7 _I--7�� Authorized Representative OR Countersignature (In states where applicable) LX9493 (Ed. 02/04) POLICY NUMBER: BAP014157402 COMMERCIAL AUTO CA 20 01 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LESSOR - ADDITIONAL INSURED AND LOSS PAYEE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Burrtec Waste Group, Inc. Endorsement Effective Date: 03/01/2019 SCHEDULE Insurance Company: ZURICH AMERICAN INSURANCE COMPANY Policy Number: BAP014157402 Effective Date: 03/01/2019 Expiration Date: 03/15/2020 Named Insured: Burrtec Waste Group, Inc. Address: Additional Insured (Lessor): ALL LESSORS WHERE REQUIRED BY WRITTEN CONTRACT Address: Designation Or Description Of "Leased Autos": ALL LEASED AUTOS CA 20 01 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 2 Coverages Limit Of Insurance Covered Autos Liability $ Each "Accident" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Comprehensive $ Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Collision $ Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Specified $ Deductible For Each Covered "Leased Auto" Causes Of Loss Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Coverage 2. The insurance covers the interest of the lessor 1. Any "leased auto" designated or described in unless the 'loss" results from fraudulent acts or the Schedule will be considered a covered omissions on your part. "auto" you own and not a covered "auto" you 3. If we make any payment to the lessor, we will hire or borrow. obtain his or her rights against any other party. 2. For a 'leased auto" designated or described in C. Cancellation the Schedule, the Who Is An Insured 1. If we cancel the policy, we will mail notice to provision under Covered Autos Liability the lessor in accordance with the Cancellation Coverage is changed to include as an Common Policy Condition. "insured" the lessor named in the Schedule. However, the lessor is an "insured" only for 2. If you cancel the policy, we will mail notice to "bodily injury" or "property damage" resulting the lessor. from the acts or omissions by: 3. Cancellation ends this agreement. a. You; D. The lessor is not liable for payment of your b. Any of your "employees" or agents; or premiums. c. Any person, except the lessor or any E. Additional Definition "employee" or agent of the lessor, operating As used in this endorsement: a "leased auto" with the permission of any "Leased auto" means an "auto" leased or rented to of the above. you, including any substitute, replacement or extra 3. The coverages provided under this "auto" needed to meet seasonal or other needs, endorsement apply to any 'leased auto" under a leasing or rental agreement that requires described in the Schedule until the expiration you to provide direct primary insurance for the date shown in the Schedule, or when the lessor. lessor or his or her agent takes possession of the "leased auto", whichever occurs first. B. Loss Payable Clause 1. We will pay, as interest may appear, you and the lessor named in this endorsement for "loss" to a 'leased auto". Page 2 of 2 © Insurance Services Office, Inc., 2011 CA 20 01 10 13 INSURED: Burrtec Waste Group, Inc. POLICY ##: BAP014157402 POLICY PERIOD: 03/01/2019 TO: 03/15/2020 0 Coverac,e Extension Endorsement — Liability Oniv ZURICH THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Business Auto Coverage Form Motor Carrier Coverage Form A. Amended Who Is An Insured 1. Thefollowingis addedtotheWho Is An Insured Provision in Section 11 — Covered Autos Liability Coverage: The following are also -insureds": a. Any"employee'ofyours is an'insurerrwhileusing acovered "auto'you don`t own, hire or borrow for acts performedwithin the scope of employment by you. Anyemployee of yours is also an 'insured' while operating an'auto' hired or rented under a contract or agreement in that employee's' name, with your permission, while performing duties related to the conduct of your business. b. Anyonevolunteeringservices to you is an 'insured' while using a covered "auto' you don`t own, hire or borrow to transportyour clients or other persons in activities necessary to your business, c. Anyone else who furnishes an "auto' referenced in Paragraphs A.1.a. and AA.b. in this endorsement. d. Where andto the extent permitted by ]avi, anypersor(s) or organization(s) whererequiredby written contract orwritten agreementwithyou executed priorto any'accident', indudingthose person(s) or organization(s) directingyourwork pursuantto suchumttencontract orwrittenagreementwithyou, provided the'accidenr arises out of operations governed by such contract or agreement and only up to the limits required in the written contract or written agreement, orthe Limits of Insurance shown inthe Declarations, whicheveris less. 2. The following is addedtotheOtherinsurance Condition in the Business Auto Coverage Form and the Other insurance — Primary and Excess Insurance Provisions Condition in the Motor Carrier Coverage Form: Coverage for any person(s)ororgan ation(s),whererequiredbywrittencordractorwritten agreementwith you executed prior to any"accident'. will apply on a primary and non-contributory basis and any insurance mairdained by the additional"insured'willapply on an excess basis. However, inno eventwillthis coverage extend beyond the terms and conditions of the Coverage Form, B. Amendment— Supplementary Payments Paragraphsa.(2) anda.(4) of the Coverage Extensions Provisionin Section ll—Covered Autos Liability Coverage are replaced by the following: (2) Up to S5,000 for the cost of bail bonds (including bonds forrelatedtrafficlaw violations) required because of an 'accidentwecover We do not have to furnish these bonds. (4) All reasonable expenses incurred by the'insured' at our request, including actual loss of earnings up to S500a day because of time off from work. C. Fellow Employee Coverage The Fellow Employee Exclusion contained in Section 11—Covered Autos Liability Coverage does not apply. D. Driver Safety Program Liability Coverage The following is added to the Racing Exclusion in Section II— Covered Autos Liability Coverage: . ...1 _. .. .. ._ ..•.. .. ..__��_. _ .. t.. airy This exclusiondoes not applyto covered "autos' participating in a driver safety program event, such as, but not limited to, auto or truck rodeos and other auto or truck agility demonstrations. E. Amended Duties In The Event Of Accident, Claim, Suit Or Loss Paragrapha. of the Duties In The Event Of Accident, Claim, Suit Or Loss Conditionis replaced by th a foUrnving: a. In the event of"accident', claim, "suiror "loss', you must giveus or our authorized representative prompt notice ofthe'accident`,claim, "suit"or'loss': However, these duties only appywhenthe`accidenr,claim,'suit'or, "loss" is known to you (if you are an individuaQ, a partner (if you area partnership), a member (if you area limited liabilitycompany)oranexecutiveofficerorinsurancemanager(ifyouareacorporation). Thefailureofany agent, s ery ant or employee ofth e'insured" ton otify us of any accident , claim, 'suit' or 'I oss""shall not invalidate the insurance afforded by this polity. Include, as soon as practicable: (1) How, when andwherethe'acddent'or"loss"occurred and if a claim is made or'suit'isbrought, written notice of the claim or "suit" including, but not limited to, the date and details of such claim or'suir; (2) The'insured•s'nameand address: and (3) To the extent possible, the names and addresses of any injured personsandwitnesses. If you report an "accident", claim,'suit" or"]oss'to another insurerwhenyou should have reported to us, your failureto report to us vnllnot be seen as aviolation of these amended duties provided you give us notice as soon as practicable after the fact ofthe delay becomes knawn to you. F. Waiver of Transfer Of Rights Of Recovery Against Others To Us The following is added to the Transfer Of Rights Of Recovery Against Others To Us Condition: This Condition does not applyto the extent required ofyou by awrltten contract, executedprior to any "accident' or 'loss", provided that the "accident"or'loss" arises out of operations contemplated bysuch contract, Thiswaiveronly applies to the person or organization designated in the contract. G. Unintentional Failure to Disclose Hazards The following is added to the Concealment, Misrepresentation Or Fraud Condition: However, we will not deny coverage under this Coverage Form if you unintentionally: (1) Fail to disclose any hazards existing at the inception date of this Coverage Form; or (2) Make an error, omission, improper description of "autos' or other misstatement of information. You must notify us as soon as possible after the discovery of any hazards or any other information that was not provided to us prior to the acceptance of this policy. H. Hired Auto —World tide Coverage Paragraph 7a.(5) of the Policy Period, Coverage Territory Condition is replaced by the following: (5) Anywhereintheworldifa covered'auto'is leased, hired, rented or borrowed for a period of 60 days or less, I. Bodily Injury Redefined The definition of 'bodily injury" in the Definitions Section is replaced by the following: 'Bodily injury'meansbodiyinjury. sickness ordisease,sustained by a person including death or mental anguish, resultingfrom anyof these at any time. Mental anguish means anytypeofmental oremotional illness ordisease, J. Expected Or Intended Injury The Expected Or Intended Injury Exclusion in Paragraph B. Exclusions under Section 11—Covered Auto Liability Coverage is replaced by the foUaving: Expected Orintended Injury 'Sod ilyinjury"or*properly damage expected orintendedfrom the standpointofthe"insured'. This exclusion does not appyto'boddyinjury'or'propertydam age'resultingfrom the use of reasonable force toprotectpersons or property. All other terms, conditions, provisions and exclusions of this policy remain the same. .i 7 . __ .. _ , ...v:E'_ _ : _ 3'_x Cf:'ti25 v `.:_. �".. w'h 'S f-�'.".•Effi' INSURED: Burrtec Waste Group, Inc. POLICY #: WC014157302 POLICY PERIOD: 03/01/2019 TO: 03/15/2020 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause' need be completed only when this endorsement is issued subsequent to preparation of the policy.) Premium (if any) $ Authorized Representative 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 % of the California workers` compensation pre- mium otherwise due on such remuneration. Schedule Person or Organization ALL PERSONS OR ORGANIZATIONS WHEN REQUIRED BY WRITTEN CONTRACT WC 252 (4-84) WC 04 03 06 (Ed, 4-84) Job Description Page 1 of 1