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WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />HARTFORD CT 06183 <br />ENDORSEMENT WC 99 03 76 ( A) - 001 <br />POLICY NUMBER: UB-7K475503-21-14-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 <br />FOR WHICH THE INSURED HAS <br />AGREED BY WRITTEN CONTRACT <br />EXECUTED 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 required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective 07-01-22 Policy No. UB-7K475503-20-14-G Endorsement No. <br />Insured Duthie Electric Service Corp dba: Duthie Power Services Premium <br />Insurance Company <br />Travelers Property Casualty Company of America <br />DATE OF ISSUE: 07-01-22 STASSIGN: <br />Countersigned by <br />RAMuaigmadDMsian <br />REVIEWED & APPROVED BY. <br />e Aeevaa <br />'�--'Risk Management Specialist <br />