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OCEAN BLUE ENVIRONMENTAL A- 2013 - 115 -02 REVIEWED BY `�� V� -.• 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 following "attaching clause" need to be completed only when this endorsement Is Issued subsequent to preparation of the <br />policy.) <br />This endorsement, effective on: 07/01/2019 <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 />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 1.00 % of total California premium. <br />Person or Organization <br />Blanket where required <br />by a written contract. <br />WC 09 03 04 (Ed. 7 -00) <br />Schedule <br />Job Description <br />Blanket where required <br />by a written contract. <br />