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A�WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 ( A) - <br />POLICY NUMBER: UBOL9415782014G <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 <br />Job Description <br />ANY PERSON OR ORGANIZATION FOR WHICH THE INSRED HAS AGREED BY WRITTEN CONTRACT <br />EXECUTED PRIOR TO LOSS TO 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 />08/27/202D <br />Endorsement Effective Policy No. Endorsement No. <br />Insured Premium <br />Bacl<flow Apparatus &Valve Company <br />Insurance Company Travelers Property Casualty Countersigned by <br />�.y�-�. w�kmBaewv>al�n <br />Company of America a;Y enm o� RE�n&APPROVED BY: <br />DATE OF ISSUE: - - ST ASSIGN: ) V F44W44 Z Vs" <br />`--�---�' ftitk l4kana9emenC Analyst <br />56994187 119-20 GL, Auto, Omb, 20-21 We I Brigitte Leber 18/12/2028 2:09:31 PM )POT) I Page 11 of 11 <br />