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TRAVELERg J WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 ( A) — <br />POLICY NUMBER. USGA526643 <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 .fable for an injury rovered by this policy. We wN not <br />enforce our right against the person or organization named in the Schedule. <br />,he adoi5onal premium for this endorsement shall be %c of the CaMomia wo-:kers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization <br />Job Description <br />FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO <br />FURNISH THIS WAIVER <br />TNs 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 propar=tion of <br />tho policy.) <br />Endorsement Effective 10/15/2012-13 Policy No. USBA526643 Endorsement Nc <br />Insured PsOm$s premiurn <br />Insurance Company Countersigned <br />DATE OF ISSUE: 10/152012-13 ST ASSIGN: Page 1 of 1 <br />