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TRAVELERS, WORKERS COMPENSATION <br /> AND <br /> ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br /> HARTFORD CT 06183 <br /> ENDORSEMENT WC 99 03 76( A)- 001 <br /> POLICY NUMBER: UB-3R155740-25-14-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.DD % 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.) <br /> Endorsement Effective 08/27/2025 Policy No. Endorsement No. <br /> Insured Backflow Apparatus &Valve Co. Premium <br /> Insurance Company Countersigned by <br /> DATE OF ISSUE:08-12-2025 ST ASSIGN: Page 1 of 1 <br />