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R �I I)ELCpCAIW WORKERS COMPENSATION <br />r I A ERS AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 99 03 76 ( A) - 001 <br />POLICY NUMBER: UB-3R155740-24-14-G <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 2.00 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization Job Description <br />ANY PERSON OR ORGANIZATION FOR ALL OPERATIONS <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO FURNISH THIS <br />WAIVER. <br />APPROVED <br />By Cynthia Mora at 2:48 pm, Dec 04, 2024 <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 08/27/2024 Policy No. Endorsement No. <br />Insured Backfiow Apparatus & Valve Co. Premium <br />Insurance Company Countersigned by <br />DATE OF ISSUE: 09-18-24 ST ASSIGN: Page 1 of 1 <br />