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TRAVELERS WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 (00) <br />POLICY NUMBER: TC2JUB-4245622A-13 <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 <br />this policy. We will not enforce our right against the person or organization named in the <br />Schedule. <br />You must maintain payroll records accurately segregating the remuneration of your <br />employees while engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be % of the California workers' <br />compensation premium otherwise due on such remuneration. <br />Schedule <br />Person or Organization <br />ANY PERSON OR ORGANIZATION <br />FOR WHOM THE NAMED INSURED <br />HAS AGREED BY WRITTEN <br />CONTRACT EXECUTED PRIOR TO <br />LOSS TO FURNISH THIS WAIVER. <br />Job Description <br />Ahechmaa Cade: 04045D <br />C nifi.te Ip: 11729371 <br />.� - t4SPE-�>t1J6li: <br />lai3z+ti,40141i:+ <br />715`.if vtixYl. j <br />1X J <br />