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i <br />TRAVELgR` <br />DHB TOWER 9QUARt <br />URTHORD, M 061,93 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 j A)— 001 <br />POLICY NUMBER: US-01<312896-21-26-0 <br />I <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT - CA UF6RNIA <br />(BLANKETWAIVER) <br />i <br />We have the rldht to recover our payments from anyone liable for an Injury covered by this policy. We will not <br />r:nfnrne our rJohIl AgalrysIthe perRnnnr nronnl7stlon named Ih the Snnedulo. <br />The. additional premium for this endorsement shall be 02.OD0 % of the California worters, compensation pre- <br />mium. <br />Person. or 01 <br />ANY PER90K <br />WHIVII THE <br />BY WRITTEN <br />PRIOR TO V <br />WAIVER, <br />FOR <br />HAs <br />Schedule <br />Job Description <br />nMn0es the policy to whtnh It La Attnohpd and is effentIM m thi: data IRsuetl unless otherwtse <br />(The Information below Is required only when this endorsement Is Issued subsequent to PreParation of <br />the policy.) <br />Endorsement Eff�ctive 03.01.2021 Policy No. UR 0K312$96-21-26-G Endorsement No. <br />Insured Premium <br />Insurance Company Countersigned by <br />DATE OF I88tig; 03.01.2021 ST.ASSIGN! I?Emeum>Rkk�Rovml B <br />o3j e <br />®. <br />® R¢k Managemen[Analyst <br />