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TRAVELERS?~ WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 ( A) - <br />POLlCY NUMBER: UB6A526643 <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 °10 of fhe Caiitornia workers' compensation pre- <br />mium_ <br />Schedule <br />Person or Organization <br />.fob Description <br />FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO <br />FURNISH THFS 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 poiicy.) <br />Endorsement Effective 'I 0/'15/20'11 Poticy No_ UB6A526643 Endorsement No. <br />Insured Psomas _ ..Premium <br />Insurance Company Countersigned by <br />DATE OF ISSLE: '10/75/11-12 ST ASSIGN: Pages ? of ?