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��A����� WORKERS COMPENSATION <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> MTPORD, CT 06183 <br /> ENDORSEMENT WC 99 03 76 t Af— 001 <br /> POLICY NUMBER:UB-A3356816-25-26-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 % of the California workers` compensation pre- <br /> mium. <br /> Schedule <br /> Person or Organization Job Descrlptlon <br /> ANY PERSON OR ORGANIZATION FOR <br /> 'HICK TSAR INSURED HAS <br /> AGREED BY WRITTEN CONTRACT <br /> EXECUTED PRIOR TO LOSS TO <br /> 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 /> Endorsement Effective 1/1/2025 Policy No. UB-A3356816--25-26-G Endorsement No, <br /> Insured Graffiti Protective Coatings,Inc. Premium <br /> Insurance Company Travelers Property&Casualty Company of America Countersigned by <br /> DATE OF ISSUE: ST ASSIGN: Page 1 of 1 <br />