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TPAV L ER47", WORKERS � M�PENSATION <br />ONE TOWER SOURS EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 0616$ <br />ENDORSEMENT WC Sia 0376 ( A)— 001 <br />POLICY NUMBER: (PJUS•1176A22-0-17) <br />WAIVER OF OUR 'BRIGHT 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 wlil not <br />enforce our right against the person or organization named in the Schedule, <br />The additional premium for this endorsement shall be 05.00 % of the California workers' compensation pre- <br />mium, <br />Schedule <br />Person or Organization Job Deacription <br />ANY PERSON OR ORGANIZATION IPOs <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO FURNISH THIS <br />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 poltey.) <br />Endorsement Effective Policy No, <br />Insured <br />Insurance Company Countersigned by <br />Endorsement No. <br />Premium <br />GATE OF ISSUE. 7!1/2017 ST ASSIGN: page 1 of 1 <br />