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<br />~ <br />TRAVELERSJ <br /> <br />WORKERseOMPENSA TION <br />AND <br />EMPLOYERS LIABILITY POLICY <br /> <br />ENDORSEMENT we 99 0376 (00) - 001 <br /> <br />POLICY NUMBER: <br /> <br />tJ'B-7 U6Y81- 4 <br /> <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT -CALIFORNIA <br />(BLANKET WAIVER) <br /> <br />We have the right to recover our payments from anyone liab.le for an injury coveted by this policy. We will not <br />enforce our right against the person or organization named in the Schedule. <br /> <br />You rnljst maintain payroll. recordslicc~rately s.egregatingthe re\TluneraUon of your employees while engaged in <br />the Work described in the Schedule. <br /> <br />The;1dditional premh.lm forthis endorsement shall bel .0 % of the California.workers'compensaticmpre- <br />mium otherwise que on such remuneration. <br /> <br />Schedule <br /> <br />Person or Organiution <br />ANY PERSON ORORGANtZATION FOR <br />WHICH THE INSOREtlHAS <br />CQloWLETED A WRITTEN A:GREEMINT <br />TQPRQVIDE THIS WAIVER <br /> <br />Job Description <br /> <br />.\fJ1ROV gO AS TO FORM <br /> <br />/l .f <br /> <br />~I\fl' P~.I,..1 <br />I Laura Stld Sheedy <br />Assistant City Attorney <br /> <br />DATE OF ISSUE: 09-15-09 STASSIGN~ <br />