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7 R VELER V WORKERSANDCOMPENSATION <br />i+A EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 0376 ( A)— 001 <br />POLICY NUMBER:' <br />UB-1R2255BA-20-26-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 .0 % 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 NAMED INSURED HAS <br />AGREED BY WRITTEN CONTRACT <br />G.YJ.SCUTBD 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 squired 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 <br />DATE OP ISSUE: <br />ST ASSIGN: <br />Countersignod by <br />&S' <br />REMEWED&APPROVEDOY;044 <br />F4"I'. I! fnutt <br />Rfak Manageme�t4 MnlysS. <br />