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TRAVELERS` WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 ( A) — <br />POLICY NUMBER: uB8M739099 <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 in the Schedule. <br />The additional premium for this endorsement shall be % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization <br />Job Description <br />Any Person or organization for which the insured has agreed by written contract executed prior to <br />loss to furnish this 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 />Insurance Company <br />Travelers Property Casualty Company of America <br />DATE OF ISSUE: 12/21/2021 <br />Countersigned by6""'�m/D <br />,� d� %ou >7itebrt <br />�Ri4 Mara9emmeClm<aiNde <br />