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TRAVELERS WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 06183 pp�� -rr gggg <br />ENDORSD"f3��588-Z1 f7G6 ( A)— Opt <br />POLICY NUMBER: <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 04.00 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization Job Description <br />ANY PERSON OR ORGANIZATION FOR <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.) 9/1/2021 UB-4J588939-21-43-G <br />Endorse%.�&*&RR tes, Inc. policy Na Endorsement No. <br />Insured Tait Environmental Services, Inc. Premium <br />Insurance Company Countersigned by <br />�oR,NCE RWtM�DMsd1mr. <br />DATE OF ISSUE: ST ASSIGN: �= REvite°&/�wPraavmBr <br />63540930 21-22 Auto/WC I Szabela Stachura 8/25/2021 9:11:48 AM (PDT) I Page 7 of 8 I—�`� Risk Management Supervisor, <br />