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OCEAN BLUE ENVIRONMENTALA-2013-115-02 REVIEWED BY EUNICE HEREDIA (PG 16 OF 16) <br />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— CALIFORNIA <br />This endorsement changes the policy to which it is attached effective on the inception date of the policy <br />unless a different date is indicated below. <br />(The fallowing "attaching clause" need to be completed only when this endorsement is issued subsequent to preparation of the <br />poky.) <br />This endorsement, effective on: 0710112015 <br />(DATE) <br />Policy No.004472796400 of the <br />issued to: <br />Endorsement No, <br />at 12,01 A. M. standard time, forms a part of <br />Federal Insurance Company <br />........... <br />Authorized Representative <br />We have the right to recover Our payments from anyone liable for an injury covered by this policy, We will <br />not enforce Our right against the person or organization named in the Schedule. The additional premium for <br />the blanket waiver offered by this endorsement shall be 100 % of total California premium, <br />Person or Organization <br />Blanket where required <br />by a written contract, <br />\NC 99 03 04 (Ed. 7-081) <br />Schedule <br />Job Description <br />Blanket where required <br />by a written contract. <br />