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TRAVELERS WORKERS COMPENSATION <br /> ONE TOWER SQUAPF EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT M6183 <br /> ENDORSEMENT WC 99 03 75 ( A)- ooi <br /> POLICY NUMBER: UB-8K37343A <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. oo % of the California workers' compensation pre- <br /> mium. <br /> Schedule <br /> Person or Organization Job Description <br /> ANY PERSON OR ORGANIZATION FOR ENGINEERS <br /> WHICH THE INSURED HAS AGREED <br /> BY WRITTEN CONTRACT EXECUTED <br /> PRIOR TO LOSS TO FURNISH THIS <br /> 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 informatiion below is required only when this endorsement is issued subsequent tD preparation of <br /> the policy.) <br /> Endorsement Effective 8f8125 Policy No. U&-81<37343A Endorsement No. <br /> Insured Jason Addison Smith Consulting Services Inc. Premium <br /> Insurance Company Countersigned b <br /> DATE OF ISSUE: 08-01-25 ST ASSIGN: Page 1 of 1 <br />