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TRA V 'L RS J WORKERS COMPENSATION <br />AND <br />ores TOWY5:2 SQU= EMPLOYERS LIABILITY POLICY <br />gAvvom, CT 665.83 <br />ENDORSEMENT WC 99 93 76 ( A} — 001 <br />POLICY NUMBER: UB4190T960 <br />T;'X-r`,F'M--UF�f I-W-ff UN -170 RECOVER FROM OTHER <br />ENDORSEMENT A'.i^1. <br />(BLANKET WAIVER) <br />We have the right to recover aur 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' compensadon 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 <br />THIS 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 Policy No, Endorsement No. <br />Insured (}^Premium <br />Insurance Company Countersigned by <br />DATE OF ISSUE: g/13/13 ST ASSIGN: Ea1)B UV1]D T�,% Ptge 1�af 4 <br />LISA t S <br />Assistant City A`itor. ` <br />