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Agbk <br />TRAVELERS, WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76(00) — 001 <br />POLICY NUMBER: UB413OT960 <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 <br />policy. We will not enforce our right against the person or organization named in the Schedule. <br />You must maintain payroll records accurately segregating the remuneration of your <br />employees while engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be 3.00 % of the California workers' <br />compensation premium otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Description <br />ALL PERSONS OR ORGANIZATIONS THAT ARE PARTIE TO A CONTRACT <br />THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT, PROVIDED YOU <br />EXECUTED THE CONTRACT BEFORE THE LOSS. <br />DATE OF ISSUE: 2 / 3 / 2 017 ST ASSIGN: CA <br />111951110141 <br />REVIEWED BY, E L J NICE - f ER - EM -- I - ' G 0 --F- <br />J <br />