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3011 <br />,�RA w / L RS WORKERS COMPENSATION <br />AND <br />EMPLOYERS LIABILITY POLICY <br />ENDORSEMENT WC9903701 A) — <br />POLICY NUM6ER: ' UB-7E37616-7-17 <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 Polley. We will not <br />enforce our right agolnsttha person or organization named In the Schedule, <br />The additional premium for this endorsement shell be % of the California workerW compansadon pre- <br />mium. <br />Schedule <br />Parson or Organization Job Description <br />Any person or organization for whichthe insured has agreed by written contract <br />executed prior to Loss to furnish this waiver. <br />This endorsement changes the pollcy In which it Is otlechad 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 07/01/17 Polley No. UB-7E37616-7-17 Endorsomon(No. <br />Insured Placewoiks premium <br />Insurance Company <br />Travelers Property Casualty of America <br />DATE OF ISSUE: - ST ASSIGN: <br />Countersigned by <br />Page t of I <br />