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S, WORKERS COMPENSATIONTRAVELER <br />AND <br />ONE TONER SWARE EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 86383 <br />ENDORSEMENT WC 99 03 76( A)— 001 <br />POLICYNUMBER: US -1339T93 -4 - <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 3 <br />mium. <br />Schedule <br />Person or Organization <br />ANY PERSON OR ORGANIZATION FOR <br />WHICH THE INSURED HAS AGREED <br />BY WRITTEN CONTRACT EXECUTED <br />PRIOR TO LOSS TO FURNISH THIS <br />WAIVER. <br />% of the California workers' compensation pre. <br />Job Description <br />This endorsement changes the policy to which it is attached and is effective on the date Issued unless otherwise <br />stated. <br />Rhe inforelatiOn below is required only when this endorsement is issued subsequent to preparation of <br />the policy.) <br />Endorsement Effective <br />Insured <br />Insurance Company. <br />DATE OF ISSUE: 11/3/16 <br />Policy No. <br />Counlersigned by <br />Endorsement No. <br />Premium <br />ST ASSIGN: Page 1 of 1 <br />