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TRAVELERS, WORKERS COMPENSATION <br />AND <br />ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY <br />HARTFORD, CT 06183 <br />ENDORSEMENT WC 99 03 76 ( A) — 001 <br />POLICY NUMBER: (XJUB-4342T25-0-17) <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 .0 % 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 <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 policy.) <br />Endorsement Effective 09/15/2017 Policy No. XJUB4342T25017 Endorsement No. <br />Insured Mark Thomas & Company, Inc. Premium <br />Insurance Company <br />Countersigned by <br />DATE OF ISSUE: 09-15-17 ST ASSIGN: Page 1 of 1 <br />REVIEWED BY: EUNICE HEREDIA (PG 7OF� <br />37738296 1 MARKT-1 1 17/18 Master Certificate I Stephanie Scheller 1 9/1.5/2017 <br />