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A01h, WORKERS <br />TRAVELERSJ COMPENSATIONAND <br />ONE TOWER SQUAR9 EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 06183 <br />ENDORSEMENT WC 99 013 76 ( A) — 001 <br />POLICY NUMBER: 'UB -7836Y'81-4 <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 />mjum. <br />Schedule <br />Person or Organization <br />ANY PERSON OR ORGANIZATION FOR <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO FURNISH THIS <br />WAIVER. <br />Job Description <br />A iTROV ED AS TO FORM <br />l.aura A. Rossini <br />Sonior Assislant City Attorney <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 <br />Insured <br />Insurance Company <br />Policy No. <br />Countersigned by <br />Endorsement No, <br />Premium <br />DATE OF ISSUE: 913114 ST ASSIGN: Page 1 of 1 <br />