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tl WORKERS COMPENSATION <br />TRAVELERS AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC990370( A) — <br />POLICY NUMEER: UB-7E37616-7-17 <br />ENDORSEMENT CALIFORNIA <br />(BLANKET WAIVER) <br />onfams our rright the panton�or organization named In the Schedule. <br />The additional premium for this andomoment shall be % of the California warkers' compensation pre. <br />ulurn. <br />Person or Organization ob Description <br />has yraal y.. wrttten contract <br />ed`p`l <br />Q�G <br />This endorsement changes the pulley to which K is attached and Is affective on the data Issued unless otherwise <br />slated. <br />(The Information below Is required only when this andorsement is Issued subsequent to preparation of <br />the policy.) <br />Endar mentEffective 07/01/17 PullcyNa. UB-7E37616-7-17 EndorsornonlNo, <br />Insured PlecawoxSco Promlum <br />Insurance Company Countersigned by <br />Travelers Property Casualty of Amar3.ca <br />DATE Of ISSUE: - - ST ASSIGN: Page I of I <br />