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TRAVELERS WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 ( A) - <br />POLICY NUMBER: UB-5R147157-21-43-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 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization Job Description <br />ANY PERSON OR ORGANIZATION FOR WHICH <br />THE INSURED HAS AGREED BY WRITTEN <br />CONTRACT EXECUTED PRIOR TO LOSS TO <br />FURNISH THIS 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 12/04/2021 Policy No. UB-51R147157-21-43-G Endorsement No. <br />Insured Premium <br />Insurance Company Countersigned byeREI <br />& JAPFIR A.81 <br />DATE OF ISSUE: - - ST ASSIGN: Ri,k Manage tClei-lA do <br />