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�RpViL�ps/� WORKERS COMPENSATION <br />RA i IIf� AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 99 03 76 ( A) - 001 <br />POLICY NUMBER: UB-5J864844-20-47-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 Job Description <br />ANY PERSON OR ORGANIZATION FOR ARCHITECTS PLAN <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. Endorsement No. <br />Insured Premium <br />Insurance Company Countersigned by <br />Rhk MnugemadDW61vn <br />% REM WED&APPROVEDBY: <br />DATE OF ISSUE: 08-14-20 ST ASSIGN: fa�wc .a Q. V tPi u[ <br />Risk Management Anelyst <br />