Laserfiche WebLink
Aw <br />TRAV L J tNaRKEE25CONlENSArioN <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENOORSEM15NT WC99037S( Ai— <br />POLICY d' UMBER, U66A526643 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT - CALIFORNIA <br />,BLANKET WAIVER) <br />We have the rght to recover our payments from anyone liable for an Injury covered by this policy. We rhlf not <br />erriw e our right against the person or organization nemaq In the Srha 1u?z . <br />me adoldrinal premium for this endorsement shalt be yrs, of the California worker; bernpensatiort pre. <br />mum. <br />Schedule <br />Person or Organization .lob Ctescriptlon <br />FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO <br />FURNISH THIS WAIVER <br />This endorsement changes the policy to which 11 Is attached and is offeolive on the date issued unless otharvise <br />stated. <br />{The infofmstion botew is foquir" Only when this Otdorsernonf is tssuod suhsaquout to proparation of <br />the policy.) <br />Endorsement Effective 10/15/2013-14 Policy No, USBA526643 Endorsement No <br />insured Psomas / ,Premium <br />insurance Company Countersignedby <br />DATA OF ISSUE00/15/2013-14 $T ASSIGN: page 1 of t <br />