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TRAVELERSJW <br />WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC 99 03 76 ( A)— <br />POLICY NUMBER: PJUB9J55881917 <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 FOR <br />WHICH THE INSURED HAS AGREED BY <br />WRITTEN CONTRACT EXECUTED PRIOR <br />TO LOSS TO FUNISH THIS WAIVER. <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 11/09/2017 Policy No. PJUB9J55881917 Endorsement No. <br />Insured Premium <br />Insurance Company Countersigned by <br />Travelers Property Casualty Company of America <br />DATE OF ISSUE: ST ASSIGN: Page 1 of 1 <br />