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TRAVELERS WORKERS COMPENSATION <br />AND <br />DIM ieaeE Boom EMPLOYERS LIABILITY POLICY <br />SAX114re, Cr 01F1113 <br />ENDORSEMENT WC 99 03 76 ( A) — 001 <br />POLICY NUMBER: UBBJ034006 <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 far an Injury covered by this policy. We will not <br />enforce our right against the person or organka0on named In the Schedule. <br />The additional premium for flits endorsement shall be 3 % of the California workers' componsallon pre- <br />mium. <br />Schedule <br />Person or Organisation Job Description <br />ANT FROM OR OROANZZA°d'IGI FOR <br />WHICH THR INSORIM HAS AORM <br />By NUMEN CORTRALT H MCSTED <br />PRIOR To TOES TO FORMSH THIS <br />WAINEER. <br />This eMorsement a MIM the pollcy to WhIch It is attached and Is effective on the dale Issued unless otherwise <br />slated. <br />(The Information below Is required only when Ibis andomemant Is Issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective <br />Insured <br />Insurance Company <br />Policy No. <br />Countersigned by <br />Endorsement No <br />Premium <br />OATS OF ISSUE ST ASSIGN: Page 1 of 1 <br />