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TRAVELERS�J� <br />ONE TOWER SQDARE <br />HARTPORD, CT 06183 <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WG 99 03 76 ( A) — 001 <br />POLICY NUMBER: �UB- 7836Y81 -4 <br />WAIVER OF OUR 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 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 PERSON OR ORGANIZATION FOR <br />WHICEi TE3E NAMED INSURED ETAS <br />AGRBED BY VPRITTEN CONTRACT <br />EXECIITED PRIOR TO LOSS TO <br />FIIRNISH THIS PIAIVER. <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 <br />Insurance Company <br />Countersigned by <br />�� <br />DATE OF ISSUE: 07 -25 -11 ST ASSIGN: Page 1 of t <br />