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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 our right <br />against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under <br />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 work <br />described in the Schedule. <br />The additional premium for this endorsement shall be 5% of the California workers' compensation premium otherwise due on such <br />remuneration. <br />Person or Organization <br />The city of Redwood city ATIMA <br />881 Middlefield Road <br />Redwood City CA 94063 <br />Schedule <br />Job Description <br />City requirement <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 5/1/2025 Policy No. TES4624347 Endorsement No. 4 <br />Insured Pacific Dining CA1 LLC Premium $ 6,592 <br />Insurance Company Technology Insurance Company, Inc. <br />Countersigned by <br />WC 04 03 06 <br />(Ed. 04-84) <br />ATTY/AGR.2025.234/Pacific Dining CA1, LLC (881 Middlefield Rd) (Page 41 of 47) <br />