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TRAVEL Ep WORItERS COMPENSATION <br />L l[4 J AND <br />EMPLOYERS LIASILfTY POLICY <br />ENDORSEMENT WC 99 03 76 f Al - <br />POLICY NUMBER U66A526643 <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 vain not <br />enforce our right against the person or organization named in the Schedule. <br />The additional premium for this endorsement shall be 0/c, of the California WO ker5' ccmpensatiaR pre- <br />miu;n. <br />Schedule <br />Person or Organization <br />Sob Description <br />FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO <br />FURNISH THIS WAIVER <br />TE is endorsement changes the policy to which it is attached and is effective on the date issued unless otherMse <br />stated. <br />(The Information below Is required only when this endorsement Is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective 10/15/2012-13 Policy No. U86A526643 Endorsement Nc <br />insured Psomas Premium <br />insurance company Countersigned by <br />DATE OF ISSUE: 10/15/2012-13 ST ASSIGN: Page 1 of 1