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WORKERS COWENSATION <br />TRAVELERS] - AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD CT O6JS3 <br />ENDORSEMENT WC 99 03 78 (A) - oBt <br />POLIcy UB-7K72867623-43-G <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT-CALIFORN <br />(BLANKET WAIVER) <br />We have the rightto recover our payments from anyone liable for an Injury covered by this policy. We will not <br />enforce outright against the person or organization named in the Schedule. <br />The additional premium for this endorsement shall be 2. 00 <br />mium. <br />Schedule <br />Person or Organization <br />ANY PERSON OR ORCANa: ZAT10 FOR <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EEECU'1'1ro <br />PRIOR TO LOSS TO FURNJ:SH TRIS <br />WAIVER. <br />% of the California workers' compensation pre - <br />Job Description <br />This endorsement changes the policy to which d 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 <br />Insured <br />Insurance Company <br />Policy No. <br />DATE OF ISSUE-07/0112021 ST ASSIGN: <br />Endorsement No. <br />Premium <br />RA Moult mad ElMsim <br />ReoEweo&APr Br <br />�' Risk Management Specialist <br />