Laserfiche WebLink
TRAVELERST WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 06123 <br />ENDORSEMENT WC 99 03 76 ( A) — DO1 <br />POLICY NUMBER: MB-329OT63 <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 03.00 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization Job Description <br />ANY PERSON OR ORGANIZATION FOR <br />WHICH TOR INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO r=ISE THIS <br />WAIVER. <br />City of Santa Ana, its appointed and elected officers, officials, and employees <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. UB329OT632 Endorsement No. <br />Insured JLee Engineering, Inc. Premium <br />Insurance Company Countersigned by I esiie Pancoast - <br />DATE OF ISSUE: ST ASSIGN: <br />Page 1 of 1 <br />0) <br />