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A06k <br />TRAVELERS, WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76(00) — 001 <br />POLICY NUMBER: WZ P8 10 3 0 0 5 6 <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 <br />policy. We will not enforce our right against the person or organization named in the Schedule. <br />You must maintain payroll records accurately segregating the remuneration of your <br />employees while engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be 3.00 % of the California workers' <br />compensation premium otherwise due on such remuneration. <br />Person or Organization <br />ALL PERSONS OR ORGANIZATIONS <br />THAT REQUIRES YOU TO OBTAIN <br />EXECUTED THE CONTRACT BEFORE <br />DATE OF ISSUE: 12/4/20x5 <br />1111VAIIII-9 <br />Schedule <br />Job Description <br />THAT ARE PARTIE TO A CONTRACT <br />THIS AGREEMENT, PROVIDED YOU <br />THE LOSS. <br />ST ASSIGN: CA <br />REVIENVED Byr, <br />El ff,,flCE I IEREDA (TI(3,2 OF <br />