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TRAVELERSJ WORKERS COMPENSATION <br />AND <br />ONE Towae spnARE EMPLOYERS LIABILITY POLICY <br />AARTFoRD, CT 06183 <br />ENDORSEMENT IMC 99 93 76 ( A) — 001 <br />POLICY NUMBER: UB413OT960 <br />ENDORSEMENTRECOVER FROM OTHER9 <br />CALIFORNIA <br />(BLANKET <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 03.00 % 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 RAS AORBED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO FURNISH <br />THIS WAIVTsR. <br />This endorsement changes Via policy to which It Is attached and is effective on the date issued unless otherwise <br />stated. <br />(Tho information below Is required only when this endorsement is Issued subsequent to preparation of <br />the policy) <br />Endorsement Effective Policy No, Endorsement No. <br />Insured Premium <br />Insurance Company Countersigned by _ �k Y�1�'t—^ <br />ki ' i f i T, o `�Cf <br />DATE OF ISSUE: 9/13/13 ST ASSIGN; 1age 1 cf t <br />LISA t., <br />ASSIStF, nt City Attorne" J I <br />