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0 <br />TRAVELERS) <br />ONE TOWER SQUARE <br />HARTFORD CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />WC 99 Q3 76 ( A)- 0o1 <br />POLICY NUMBER: UB-BK37343A <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT - CALIFORNIA <br />(BLANKET WAIVER) <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not <br />enforce our right against the person or organization named m the Schedule. <br />The additional premium for this endorsement shall be 2. oo % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization lob Description <br />ANY PERSON OR ORGANIZATION FOR ENGINEERS <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO FURNISH THIS <br />WAIVER. <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise <br />stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective Policy No. Endorsement No. <br />Insured Premium <br />Insurance Company Countersigned by <br />+"'•`=e RAM0ag0WdDMs1an <br />Re EWED&APPRovmft <br />DATE OF ISSUE: 08-01-21 ST ASSIGN: A4ju A,,v44 <br />�� Rnk Management SpedAm <br />