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WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />WC 99 03 04 (Ed, 7.08) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - <br />CALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a diffa ent date is <br />indicated below. <br />(Ilm following "eueebing elan." need be completed only when this endmenicw is ix,ncd snbsegn,,n to puepnretion of dte policy.) <br />This cndorsemeng effective on 4/30/2016 at 12:01 A.M. standard time, forms a part of <br />PATE) <br />Policy No. 71750505 of the FEDERAL INSURANCE COMPANY <br />(NAME OF INSURANCE COMPANY) <br />issued to BEST HEST & KRIEGER LLP <br />Endorsement No. <br />We have the tight to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right <br />against the person or ogMnizaticil named in the Schedule. The additional premium for the blanket waiver offered by this endorsement <br />shall be 1.00% of total California premium <br />Schedule <br />Person or Organization <br />BLANKET WAIVER -ANY PERSON OR ORGANIZATION FOR <br />WHOM THF, NAMED INSURED HAS AGREED 13Y WRITTEN <br />CON'PItACTTO FURNISH THIS WAIVER <br />WC 99 03 04 (li:D. 7.08 <br />Attachment Code: D466017 <br />Certificate ID: 11767171 <br />Jab Description <br />ALL CALIFORNIA OPERATIONS <br />Page 1 of 1 <br />;*� <br />PQR®V�'i ASTo FORM <br />�/ Schwarzmann <br />SeniorAsstant City Attorney <br />