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Albert Grover & Associates, Inc. <br />TRAVELERS <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 (00) <br />POLICY NUMBER: UB6676Y748 <br />WAIVER OF 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 employees <br />while engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be 3% of the California workers' <br />compensation premium otherwise due on such remuneration. <br />SCHEDULE <br />PERSON OR ORGANIZATION <br />ALL PERSONS OR ORGANIZATIONS <br />THAT ARE PARTIES TO A CONTRACT <br />THAT REQUIRES YOU TO OBTAIN <br />THIS AGREEMENT PROVIDED YOU <br />EXECUTED THE CONTRACT BEFORE <br />THE LOSS. <br />DATE OF ISSUE: 11/2/2010 <br />CE:R'1 NO.: 8705605 Pauline Bingham 11/2/2010 9:56:15 AM Page 4 of 4 <br />JOB DESCRIPTION <br />