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CNA Workers Compensation And Employers Liability Insurance <br /> Policy Endorsement <br /> BLANKET WAIVER • • • • - OTHERS <br /> FM <br /> This endorsement changes the policy to which it is attached. <br /> It is agreed that Part One - Workers' Compensation Insurance G. Recovery From Others and Part Two - <br /> Employers' Liability Insurance H. Recovery From Others are amended by adding the following: <br /> We will not enforce our right to recover against persons or organizations. (This agreement applies only to the <br /> extent that you perform work under a written contract that requires you to obtain this agreement from us.) <br /> PREMIUM CHARGE - Refer to the Schedule of Operations <br /> The charge will be an amount to which you and we agree that is a percentage of the total standard premium for <br /> California exposure. The amount is 3%. <br /> All other terms and conditions of the policy remain unchanged. <br /> This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, <br /> takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another <br /> effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy <br /> unless another expiration date is shown below. <br /> Rick Management DMsian <br /> Form No: G-19160-B (11-1997) o? RE)AEWED&APPROVLDBY. <br /> Endorsement Effective Date: Endorsement Expiration Date: A Aecv4o <br /> Endorsement No: 3; Page: 1 of 1 ®' Risk Management Specialist <br /> Underwriting Company: Valley Forge Insurance Company, 151 N Franklin St, Chicago, IL 60606 <br /> °Copyright CNA All Rights Reserved. <br />