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iiioMmiiwul9iuudu i �uw.+id +illw�xi�x&w�'wmu'"' � uw,�nuu�x��ii uutiN�pMUUNi44ugduwuawm.: u�rvw��u Liw ^ ^°°°° w,31u. ��� .: giiuYY�iuuouerw+.rw+wWwwm��ti i„ ww. �. aauv�wu��r ^ww�w�wuuwOYiiew.�w�Y�uiWwrr. u <br />TRAVELERS J WORKERS COMPENSATION <br />AND <br />oxs Towax sQa�RS EMPLOYERS LIABILITY POLICY <br />BARTffORD, LZ 06183 <br />ENDORSEMENT WC 99 03 76 ( A) - 001 <br />POLICY NUMBER: •t7H- 7836Y81 -4 <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />ENDORSEMENT - CALtFORN1A <br />(BLANKET WAIVER) <br />We have the right to recover our payments from anyone stable 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 3 _ 00 % of the California workers' compensation pre- <br />mium_ <br />Schedule <br />Person or Organization Job Description <br />ANY PBRSON OR ORQAN2ZATION FOR <br />➢PHSCH T88 NAI'® INSIIRBD HAS <br />AGRSSD HY SPR2TTffii CONTRACT <br />EX13ClITED PRIOR TO T,033 TO <br />I?IIRNIS.H TBIS WAIVBR. <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 ----� Pr$mit�m <br />Insurance Company Countersigned by �" �''' - — — ` <br />DATE OF ISSUE: 07 -25 -11 ST ASSIGN: Page 1 of t <br />