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TRAVELERS J k WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 99 03 76 ( A) - 001 <br />POLICY NUMBER: UB-9K107321-18-14-G <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 2.00 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization .lob Description <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 />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 policy.) <br />Endorsement Effective Policy No. End ementfftNo1 <br />Insured reitt <br />Insurance Company Countersigned <br />DATE OF ISSUE: 06-14-18 ST ASSIGN: Page 1 of 1 <br />REVIEWED BY: EUNICE HEREDIA (PG I(OFC% ) <br />