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TRAVELERS Jam' <br />ONE TOWER SQUARE <br />HARTFORD CT 06163 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 ( A) <br />POLICYNUMBER: UE-Ss034009 <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 3.00 % of the Callrornia workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization Job Description <br />ANY PERSON OR ORGANIZATION FOR ENGINEERS PLAN <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LASS TO FURNISH THIS <br />NAME. <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 <br />Insured <br />DATE OF ISSUE: <br />Policy No. <br />Countersigned by <br />ST ASSI I 1 611 <br />Endorsement No. <br />Premium <br />Page 1 of 1 <br />