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(Page 4 of 6) <br />Rightfax N2 -1 <br />TRAVELERS) <br />ONE TOWER SQUARE <br />HARTFORD, CT D6181 <br />3/20/2015 3:25 :46 AM PACE 4/006 Fax Server <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 ( A) - 001 <br />POLICYNUMBER: (IJUB- 3F64983 -6 -15) <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 7 .0 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization <br />ANY PERSON OR ORGANIZATION FOR <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO FURNISH THIS <br />WAIVER. <br />Job Description <br />rU <br />1 <br />This endorsement changes the policy to which It Is attached and is effective an 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 Policy No. Endorsement No. <br />Insured _ /7 Prenk V <br />Insurance Company <br />DATE OF ISSUE: 01 -19 -15 ST ASSIGN: <br />Countcrsigi <br />