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G -19160-B <br />CNA (Ed. 11/97) <br />Policy Numbers: 6024533076 & 6024533062 <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY <br />BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS <br />This endorsement changes the policy to which it is attached. <br />It is agreed that Part One Workers' Compensation Insurance G. Recovery From Others and Part Two Employers' <br />Liability Insurance H. Recovery From Others are amended by adding the following: <br />We will not enforce our right to recover against persons or organizations. (This agreement applies only to the extent that <br />you perform work under a written contract that requires you to obtain this agreement from us.) <br />PREMIUM CHARGE- $328 <br />The charge will be an amount to which you and we agree that is a percentage of the total standard premium for California <br />exposure. The amount is 2.%. <br />G -19160-B Page 1 of 1 <br />(Ed. 11/97) <br />