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M WORKERS CAOM PENSATION <br />TRAmg <br />ONE TOWER 8QHARE I� EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 06193 <br />ENDORSEMENT WC 99 03 76 ( A) — 001 <br />POLICY NUMBER: 'UB -7836Y81-4 <br />ENDORSEMENTif <br />•^ A. <br />(BLANKET WA 'w <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 ,lob Description <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 />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 Premium <br />Insurance Company Countersigned by n <br />DATE OF ISSUE: 08-27-13 ST ASSIGN: Page 1 of 1 <br />