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TANKO LIGHTING AGR# TBD <br />TRAVELEF75' J <br />REVIEWED BY: <br />EUNICE HEREDIA (PG 16 OF 17) <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />WC 99 03 76 ( A)— <br />POLICY <br />)— <br />POLICY NUMBER: UB -4E96385-4-15 <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 % of the California workers' compensation pre- <br />mium. <br />Schedule <br />Person or Organization Job Description <br />Any person or organization requiring waiver of subrogation by written contract for work <br />performed by or on the insured's behalf <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 05/19/15 Policy No. UB -4E96385-4-15 Endorsement No, <br />Insured Tanko Street Lighting, Inc. Premium <br />Insurance Company <br />Travelers Property Casualty Co of America <br />Countersigned by <br />DATE OF ISSUE: ST ASSIGN: Page 1 of 1 <br />