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( _ < j' <br />TRAVELERS/w~ WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 (00) - 001 <br />POLICY NUMBER: (PSUS-sissN3s=A-os)_ _.. <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 />You must maintain payroll records accurately segregating the remuneration of your employees while engaged in <br />the work described in the Schedule. <br />The additional premium for this endorsement shall be 2 % of the Galifornla workers' compensation pre- <br />mium otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />ANY PERSON OR ORGANIZATION <br />FOR WHICH THE INSURED HAS <br />COMPLETED A WRITTEN <br />AGREEMENT TO PRDVIDE THIS <br />WAIVER. <br />DATE OF ISSUE: os-o3-os ST ASSIGN: <br />