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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />WC 04 03 06 <br />(Ed. 04-84) <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 <br />our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you <br />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 <br />engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be 5 % of the California workers' compensation premium <br />otherwise due on such remuneration. <br />Work performed by <br />LA VIGA CULINARY, INC at: <br />2042 Broadway St <br />Redwood City, CA, 94063-1802 <br />Schedule <br />Subrogant Information Class Code Description <br />The City of Redwood City, and its 9079 <br />Council, officers, officials, <br />employees, and agents <br />1017 Middlefield Road <br />Redwood City, CA, 94063 <br />Restaurants Or Taverns <br />Payroll <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: 10/10/2024 Policy No. MWC0186462-04 Endorsement No. <br />Insured: LA VIGA CULINARY, INC <br />Insurance Company: Markel Insurance Company <br />Countersigned by <br />say-da4q___de7 <br />Premium $(See <br />Attached) <br />WC 04 03 06 © 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the <br />(Ed. 04-84) WCIRB's California Workers' Compensation Insurance Forms Manual © 2001 <br />ATTY/AGR.2024.212/La Viga (1772 Broadway) (Page 25 of 25) <br />Page 1 of 1 <br />